Form Ad 586 Relinquishment In Or Out-Of-County (Alleged Natural Father In California)
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1STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT
In or Out-of-County
(Alleged Natural Father in California)
Complete this section before sending this form to an out-of-county
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.
By ___________________________________
AUTHORIZED AGENCY OFFICIAL
I, _____________________________ , having been alleged to be the father of ___________________________________________,
NAME OF ALLEGED NATURAL FATHER
NAME OF CHILD
a minor ______ child born on_______________________ in _________________________________________ do hereby relinquish
STATE
GENDER
DATE
CITY
the said 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 PARENTS
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.
SIGNATURE OF ALLEGED NATURAL FATHER
DATE
The foregoing relinquishment was signed on __________________ by __________________________________________________
DATE
NAME OF ALLEGED NATURAL FATHER
in the presence of:
NAME OF WITNESS
SIGNATURE OF WITNESS
NAME OF WITNESS
SIGNATURE OF WITNESS
STATE OF CALIFORNIA
}
COUNTY OF ___________________________________
ss.
On this ____________ day of _____________________ , 20______, before me, ______________________________________ , an
NAME OF AUTHORIZED AGENCY OFFICIAL
authorized official of the ________________________________________________________________________an organization
NAME OF AGENCY
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, personally appeared _____________________________________________
NAME OF ALLEGED NATURAL FATHER
known to me to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the
same.
I certify under PENALTY OF PERJURY under the laws of the State of California the foregoing paragraph is true and correct.
__________________________________________________
__________________________________________
TITLE
SIGNATURE OF AUTHORIZED OFFICIAL
AD 586 (ENG/SP) (7/14) REPLACES AD 928
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