Form Ad 867 Relinquishment Of An Indian Child Out-Of-State
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1STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
RELINQUISHMENT OF AN INDIAN CHILD
Out-of-State
(Presumed Father Denies He is the Birth Father)
NAME OF CHILD’S TRIBE
ROLL NUMBER OR OTHER EVIDENCE OF TRIBAL AFFILIATION
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.
By
(AUTHORIZED AGENCY OFFICIAL)
I, ___________________________________, being presumed by law to be the father of _____________________________,
(NAME OF PRESUMED FATHER)
(NAME OF CHILD)
a minor _________ child, born on ___________________ in ___________________________________________________,
(GENDER)
( DATE)
(CITY, STATE)
do hereby relinquish and 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 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, and the relinquishment will be binding with the signing of the decree of adoption unless I withdraw said
relinquishment before the decree of adoption is signed. I declare I am not the birth father of the child and am executing this
relinquishment to adoption solely for the purpose of promoting the welfare of the child by facilitating the child’s placement for
adoption.
_________________________
________________________________________________
(DATE)
(SIGNATURE OF PRESUMED FATHER)
)
STATE OF ____________ ___________
)
COUNTY OF _____________________
)
On _____________________________________ before me, _____________________________________________________________ ,
(NAME OF AUTHORIZED OFFICIAL)
_______________________________ of the ________________________________________________________________________ , an
(TITLE)
(NAME OF AGENCY)
organization licensed or otherwise approved to provide adoption services under the laws of _____________________________ , personally
(NAME OF STATE)
appeared ______________________________________________________________ , proved to me on the basis of satisfactory evidence
(NAME OF PRESUMED FATHER)
to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized
capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the
instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
(SIGNATURE OF AUTHORIZED OFFICIAL)
CERTIFICATION
The terms and consequences of the voluntary signing of the relinquishment, including the right to withdraw the relinquishment prior to the
signing of the decree of adoption, were fully explained in detail to and understood by the parent of this Indian child. The explanation was
given by the agency representative whose signature is affixed above, in my presence, and in a language understood by the parent.
(SUPERIOR COURT)
(DATE)
(SIGNATURE OF JUDGE)
AD 867 (3/08)
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