Form Ad 593 Relinquishment Out-Of-State Outside Of California In Armed Forces
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
Out-of-State
Outside of California in Armed Forces
(Alleged Natural Father)
Complete upper section before sending this form out-of-state
to have the annexed relinquishment taken.
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.
By ___________________________________
(AUTHORIZED AGENCY OFFICIAL)
I,_______________________________________________________________________having been alleged to
(NAME OF ALLEGED NATURAL FATHER)
be the father of ________________________________________________________________, a minor ____________
(NAME OF CHILD)
(GENDER)
child, born on _______________________ , at ___________________________________________________________
(DATE)
(CITY)
(STATE)
do hereby relinquish and surrender the child for adoption to _________________________________________________
( NAME OF AGENCY)
(
)
_________________________________________________________________________________________________
(AGENCY ADDRESS)
TELEPHONE NUMBER)
(
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.
______________________________________
______________________________________________________
(DATE)
(SIGNATURE OF ALLEGED NATURAL FATHER)
On this ________day of _________________, 20 _________, before me, ____________________________________
NAME OF OFFICER)
(
the undersigned officer, personally appeared ____________________________________________________________
NAME OF ALLEGED NATURAL FATHER)
(
known to me (or satisfactorily proven) to be (a) serving in the armed forces of the United States, (b) a spouse of a person
serving in the armed forces of the United States, or (c) a person serving with, employed by, or accompanying the armed
forces of the United States outside the United States and outside the Canal Zone, Puerto Rico, Guam and the Virgin
Islands, and to be the person whose name is subscribed to the within instrument and acknowledged that he executed the
same. And the undersigned does further certify that he/she is at the date of this certificate a commissioned officer of the
armed forces of the United States having the general powers of a notary public under the provisions of Section 936 or
1044a of Title 10 of the United States Code (Public Law 90-632 and 101-510) (Per California Civil Code Section 1183.5).
(
SIGNATURE OF OFFICER AND SERIAL NUMBER, RANK,
BRANCH OF SERVICE AND CAPACITY IN WHICH SIGNED
.)
AD 593 (9/03)
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