Form Ad 501a Relinquishment Out-Of-State - California Department Of Social Services
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
Out-of-State
(Birth Mother/Biological Father/Presumed Father)
Complete upper section before sending this form to an out-of-state agency that has been requested to take the annexed relinquishment.
On this________day of______________, 20______, the_________________________________________________
(NAME OF AGENCY)
hereby signifies its willingness to accept the annexed relinquishment and to accept said minor child for adoption.
Pursuant to California Family Code Section 8700(c), a licensed California adoption agency may not accept a relinquishment from a parent
not residing in California unless the minor child is already in the care of the licensed California adoption agency.
By _____________________________________
(AUTHORIZED AGENCY OFFICIAL)
I, ____________________________, the mother/father of _____________________________________________________________, a
(NAME OF CHILD)
(NAME OF PARENT)
minor ___________child, born on _________________________, in ___________________________________ do hereby relinquish and
(DATE)
(GENDER)
(CITY)
(STATE)
surrender the child for adoption to
_____________________________________________________________________________________________________________
(NAME OF AGENCY)
(
)
________________________________________________________________________________________________________________
(TELEPHONE NUMBER)
(AGENCY ADDRESS)
an organization licensed by the California Department of Social Services or authorized by Welfare and Institutions Code Section 16130 to
find homes for children and to place children in homes for adoption.
■ ■
I am not naming the prospective adoptive parent(s) for my child.
■ ■
I am naming the following person(s) as the prospective adoptive parent(s)
.
(FULL NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S))
If my child is not placed in the home of the named person(s) or my child is removed from the home before the adoption is completed,
the agency will notify me. I will have 30 days from the date of the notice to rescind the relinquishment, take no action or select another
placement for my child. If I do not rescind the relinquishment within the 30-day period, the agency may place the child in a home that
the agency selects.
I fully understand that when this relinquishment is filed with and acknowledged by the California Department of Social Services, all my rights
to the custody, services and earnings of the child and any responsibility for the care and support of the child will be terminated.
)
STATE OF ________________________
)
(SIGNATURE OF PARENT)
)
COUNTY OF ___________ ___________
On ___________________________________ before me, ____________________________________________________________,
(NAME OF AUTHORIZED OFFICIAL)
(DATE)
_________________________________________ of the ____________________________________________________________, an
(TITLE)
(NAME OF AGENCY)
organization licensed or otherwise approved to provide adoption services under the laws of ____________________________________,
(NAME OF STATE)
personally appeared _____________________________________________________, personally known to me (or proved to me on the
(NAME OF RELINQUISHING PARENT)
basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she
executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of
which the person acted, executed the instrument.
(SIGNATURE OF AUTHORIZED OFFICIAL)
*** COMPLETED BY NOTARY PUBLIC ***
When the form is NOT BEING signed in the presence of an agency representative
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
DATE:
SIGNATURE OF NOTARY:
AD 501A (ENG/SP) (9/14) (Per Family Code Section 8700 (c))
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