2017 Georgia Code
Title 19 - Domestic Relations
Chapter 8 - Adoption
Article 1 - General Provisions
§ 19-8-26. How surrender of parental rights executed; how and when surrender may be withdrawn; forms

SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are

surrendering all of your right, title, and claim to the child identified

herein, so as to facilitate the child's placement for adoption. You are to

receive a copy of this document and as explained below have the right to

withdraw your surrender within ten days from the date you sign it.

---------------------

I, the undersigned, being solicitous that my (male) (female) child, born (

____ ) on ( ____ ), should receive the

benefits and advantages of a good home, to the end that (she) (he) may be

fitted for the requirements of life, consent to this surrender.

I, the undersigned, ( ____ ) of the aforesaid

child, do hereby surrender the child to ( ____

____ ) and promise not to

interfere in the management of the child in any respect whatever; and, in

consideration of the benefits guaranteed by ( ____

____ ) in thus providing

for the child, I do relinquish all right, title, and claim to the child

herein named, it being my wish, intent, and purpose to relinquish

absolutely all parental control over the child.

Furthermore, I hereby agree that the ( ____

____ ) may seek for the

child a legal adoption by such person or persons as may be chosen by the (

____

____ ) or its authorized agents, without further notice to me. I do,

furthermore, expressly waive any other notice or service in any of the

legal proceedings for the adoption of the child.

Furthermore, I understand that under Georgia law the Department of Human

Services or the child-placing agency is required to conduct an

investigation and render a report to the court in connection with the legal

proceeding for the legal adoption of the child and I hereby agree to

cooperate fully with such department or agency in the conduct of its

investigation.

Furthermore, I hereby certify that I have received a copy of this

document and that I understand I may only withdraw this surrender by giving

written notice, delivered in person or mailed by registered mail or

statutory overnight delivery, to ( ____

____ ) within ten days

from the date hereof; that the ten days shall be counted consecutively

beginning with the day immediately following the date hereof; however, if

the tenth day falls on a Saturday, Sunday, or legal holiday then the last

day on which the surrender may be withdrawn shall be the next day that is

not a Saturday, Sunday, or legal holiday; and I understand that it may NOT

be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this surrender document and do

so freely and voluntarily.

Witness my hand and seal this ____ day of ____, ____.

____ (SEAL)

(Parent or guardian)

____

Unofficial witness

____

Notary public

SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are surrendering

all of your right, title, and claim to the child identified herein so as to

facilitate the child's placement for adoption. You are to receive a copy of

this document and as explained below have the right to withdraw your surrender

within ten days from the date you sign it.

---------------------

I, the undersigned, being solicitous that my (male) (female) child, born (

____ ), on ( ____ ), should receive

the benefits and advantages of a good home, to the end that (she) (he) may

be fitted for the requirements of life, consent to this surrender.

I, the undersigned, ( ____ ) of the aforesaid

child, do hereby surrender the child to ( ____

____ ), PROVIDED that each

such person is named as petitioner in a petition for adoption of the child

filed in accordance with Article 1 of Chapter 8 of Title 19 of the Official

Code of Georgia Annotated within 60 days from the date hereof. Furthermore,

I promise not to interfere in the management of the child in any respect

whatever; and, in consideration of the benefits guaranteed by ( ____

____ ) in

thus providing for the child, I do relinquish all right, title, and claim

to the child herein named, it being my wish, intent, and purpose to

relinquish absolutely all parental control over the child.

It is also my wish, intent, and purpose that if each such person is not

named as petitioner in a petition for adoption as provided for above within

the 60 day period, other than for excusable neglect, or, if said petition

for adoption is filed within 60 days but the adoption action is dismissed

with prejudice or otherwise concluded without an order declaring the child

to be the adopted child of each such person, then I do hereby surrender the

child as follows:

(Mark one of the following as chosen)

I wish the child returned to me, and I expressly acknowledge that

this provision applies only to the limited circumstance that the child

is not adopted by the person or persons designated herein and further

that this provision does not impair the validity, absolute finality, or

totality of this surrender under any circumstance other than the failure

of the designated person or persons to adopt the child and that no other

provision of this surrender impairs the validity, absolute finality, or

totality of this surrender once the revocation period has elapsed; or

I surrender the child to ( ____

____ ), a licensed child-placing agency, for placement

for adoption; or

I surrender the child to the Department of Human Services, as provided

by subsection (k) of Code Section 19-8-5, for placement for adoption;

and ( ____ ) or the

Department of Human Services may petition the superior court for custody

of the child in accordance with the terms of this surrender.

Furthermore, I hereby agree that the child is to be adopted either by

each person named above or by any other such person as may be chosen by the

( ____ ) or the

Department of Human Services and I do expressly waive any other notice or

service in any of the legal proceedings for the adoption of the child.

Furthermore, I understand that under Georgia law an evaluator is

required to conduct and provide to the court a home study and make

recommendations to the court regarding the qualification of each person

named above to adopt a child concerning the circumstances of placement of

my child for adoption. I hereby agree to cooperate fully with such

investigations.

Furthermore, I understand that under Georgia law, an agent appointed by

the court is required to conduct an investigation and render a report to

the court in connection with the legal proceeding for the legal adoption of

the child, and I hereby agree to cooperate fully with such agent in the

conduct of this investigation.

Furthermore, I hereby certify that I have received a copy of this

document and that I understand I may only withdraw this surrender by giving

written notice, delivered in person or mailed by registered mail or

statutory overnight delivery, to ( ____

____ ) within ten days from the date hereof;

that the ten days shall be counted consecutively beginning with the day

immediately following the date hereof; provided, however, that if the tenth

day falls on a Saturday, Sunday, or legal holiday, then the last day on

which the surrender may be withdrawn shall be the next day that is not a

Saturday, Sunday, or legal holiday; and I understand that it may NOT be

withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this surrender document and do

so freely and voluntarily.

Witness my hand and seal this ____ day of ____, ____.

____ (SEAL)

(Parent or guardian)

____

Unofficial witness

Sworn to and subscribed

before me this ____

day of ____, ____.

____

Notary public (SEAL)

My commission expires ____.

SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO ALLEGED BIOLOGICAL FATHER:

This is an important legal document and by signing it you are

surrendering all of your right, title, and claim to the child identified

herein, so as to facilitate the child's placement for adoption. You are to

receive a copy of this document and as explained below have the right to

withdraw your surrender within ten days from the date you sign it.

---------------------

I, the undersigned, alleged biological father of a (male) (female)

child, born ( ____ ) to ( ____ ) on (

____ ), being solicitous that said child should

receive the benefits and advantages of a good home, to the end that (she)

I, the undersigned, do hereby surrender the child. I promise not to

interfere in the management of the child in any respect whatever; and, in

consideration of the benefits provided to the child through adoption, I do

relinquish all right, title, and claim to the child herein named, it being

my wish, intent, and purpose to relinquish absolutely all control over the

child.

Furthermore, I hereby agree that the child is to be adopted and I do

expressly waive any other notice or service in any of the legal proceedings

for the adoption of the child.

Furthermore, I understand that under Georgia law an agent appointed by

the court is required to conduct an investigation and render a report to

the court in connection with the legal proceeding for the legal adoption of

the child and I hereby agree to cooperate fully with the agent appointed by

the court in the conduct of this investigation.

Furthermore, I hereby certify that I have received a copy of this

document and that I understand I may only withdraw this surrender by giving

written notice, delivered in person or mailed by registered mail or

statutory overnight delivery, to ( ____

____

____ )

within ten days from the date hereof; that the ten days shall be counted

consecutively beginning with the day immediately following the date hereof;

however, if the tenth day falls on a Saturday, Sunday, or legal holiday

then the last day on which the surrender may be withdrawn shall be the next

day that is not a Saturday, Sunday, or legal holiday; and I understand that

it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this surrender document and do

so freely and voluntarily.

Witness my hand and seal this ____ day of ____, ____.

____ (SEAL)

(Alleged biological father)

____

Unofficial witness

Sworn to and subscribed

before me this ____

day of ____, ____.

____

Notary public (SEAL)

My commission expires ____.

SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are

surrendering all of your right, title, and claim to the child identified

herein, so as to facilitate the child's placement for adoption. You are to

receive a copy of this document and as explained below have the right to

withdraw your surrender within ten days from the date you sign it.

---------------------

I, the undersigned, being solicitous that my (male) (female) child, born

( ____ ), on ( ____ ), should receive

the benefits and advantages of a good home, to the end that (she) (he) may

be fitted for the requirements of life, consent to this surrender.

I, the undersigned, ( ____ ) of the aforesaid

child, do hereby surrender the child to ( ____

____ ) and promise not to interfere in the management of

the child in any respect whatever; and, in consideration of the benefits

guaranteed by ( ____ ) in

thus providing for the child, I do relinquish all right, title, and claim

to the child herein named, it being my wish, intent, and purpose to

relinquish absolutely all parental control over the child.

Furthermore, I hereby agree that ( ____

____ ) may initiate legal proceedings for the legal adoption

of the child without further notice to me. I do, furthermore, expressly

waive any other notice or service in any of the legal proceedings for the

adoption of the child.

Furthermore, I understand that under Georgia law the Department of Human

Services may be required to conduct an investigation and render a report to

the court in connection with the legal proceeding for the legal adoption of

the child and I hereby agree to cooperate fully with the department in the

conduct of its investigation.

Furthermore, I hereby certify that I have received a copy of this

document and that I understand I may only withdraw this surrender by giving

written notice, delivered in person or mailed by registered mail or

statutory overnight delivery, to ( ____

____ ) within ten days from the date hereof; that the

ten days shall be counted consecutively beginning with the day immediately

following the date hereof; however, if the tenth day falls on a Saturday,

Sunday, or legal holiday then the last day on which the surrender may be

withdrawn shall be the next day that is not a Saturday, Sunday, or legal

holiday; and I understand it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this surrender document and do

so freely and voluntarily.

Witness my hand and seal this ____ day of ____, ____.

____ (SEAL)

(Parent or guardian)

____

Unofficial witness

____

Notary public

PRE-BIRTH SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO ALLEGED BIOLOGICAL FATHER

This is an important legal document and by signing it you are surrendering any and all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You have the right to wait to execute a Surrender of Rights Final Release for Adoption after the child is born, but by signing this document you are electing to surrender your rights prior to the birth of this child. You are to receive a copy of this document and as explained below have the right to withdraw your pre-birth surrender within ten days from the date you sign it.

---------------------

I, the undersigned, understand that I have been named by ____, the mother of the child expected to be born in ____(city) ____(county) ____(state) on or about the ____day of ____(month), ____(year), as the biological father or possible biological father of her child. I further understand that the mother wishes to place this child for adoption.

To the best of my knowledge and belief, the child has not been born as of the date I am signing this pre-birth surrender; however, if in fact the child has been born, this surrender shall have the same effect as if it were a surrender executed following the birth of the child.

I understand that by signing this document I am not admitting that I am the biological father of this child, but if I am, I hereby agree that adoption is in this child's best interest. I consent to adoption of this child by any person chosen by the child's mother or by any public or private child-placing agency without further notice to me. I expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.

I understand that I have the option to wait until after the child is born to execute a surrender of my rights (with a corresponding ten-day right of withdrawal) and, further, that by executing this document I am electing instead to surrender my rights before the child's birth.

I further understand that execution of this document does not fully and finally terminate my responsibilities until a final order of adoption is entered. I understand that if the child is not adopted, legal proceedings can be brought to establish paternity, and I may become liable for financial obligations related to the birth and support of this child.

Furthermore, I hereby certify that I have received a copy of this document and that I understand that I may only withdraw this pre-birth surrender by giving written notice, delivered in person or by statutory overnight delivery or registered mail, return receipt requested, to ____ within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof; that, however, if the tenth day falls on a Saturday, Sunday, or legal holiday, then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and that it may NOT be withdrawn thereafter.

If prior to my signing this pre-birth surrender I have registered on Georgia's putative father registry then if I do not withdraw this surrender within the time permitted, I waive the notice I would be entitled to receive pursuant to the provisions of Code Section 19-8-12 of the Official Code of Georgia Annotated because of my registration on the putative father registry.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and do so freely and voluntarily.

Witness my hand and seal this ____day of ____, ____.

____(SEAL)

Alleged biological father

____

Unofficial Witness

Sworn to and subscribed

before me on this ____ day of

____, ____.

____

Notary Public

Seal

My commission expires: ____.

ACKNOWLEDGMENT OF SURRENDER

OF RIGHTS

By execution of this paragraph, the undersigned expressly acknowledges:

• (A) That I have read the accompanying SURRENDER OF RIGHTS/FINAL

  RELEASE FOR ADOPTION relating to said minor child born ( ____

  ____ ), a (male) (female) on ( ____ );

• (B) That I understand that this is a full, final, and complete

  surrender, release, and termination of all of my rights to the child;

• (C) That I have the unconditional right to revoke the surrender by

  giving written notice, delivered in person or mailed by registered mail

  or statutory overnight delivery, to ( ____

  ____ ) not later than ten days

  from the date of the surrender and that after such ten-day period I

  shall have no right to revoke the surrender;

• (D) That the ten days shall be counted consecutively beginning with

  the day immediately following the date the surrender is executed;

  however, if the tenth day falls on a Saturday, Sunday, or legal holiday

  then the last day on which the surrender may be withdrawn shall be the

  next day that is not a Saturday, Sunday, or legal holiday;

• (E) That I have read the accompanying surrender and received a copy

  thereof;

• (F) That any and all questions regarding the effect of said surrender

  and its provisions have been satisfactorily explained to me;

• (G) That I have been afforded an opportunity to consult with counsel

  of my choice prior to execution of the surrender; and

• (H) That the surrender of my rights has been knowingly,

  intentionally, freely, and voluntarily made by me.

  Witness my hand and seal this ____ day of ____, ____.

  ____ (SEAL)

  (Parent, guardian, or biological father)

  ____

  Unofficial witness

  ____

  Notary public

• (1) The affidavit shall set forth:
  • (A) Her name;
  • (B) Her relationship to the child;
  • (C) Her age;
  • (D) Her marital status;
  • (E) The identity and last known address of any spouse or former spouse;
  • (F) The identity, last known address, and relationship to the mother of the biological father of her child, provided that the mother shall have the right not to disclose the name and address of the biological father of her child should she so desire;
  • (G) Whether or not the biological father of the child has lived with the child, contributed to its support, provided for the mother's support or medical care during her pregnancy or during her hospitalization for the birth of the child, or made an attempt to legitimate the child; and
  • (H) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of the child, or the placement or arranging for the placement of the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the mother need only state the nature of the assistance received; and

• (2) The affidavit shall conform substantially to the following form:

  MOTHER'S AFFIDAVIT

  NOTICE TO MOTHER:

  This is an important legal document which deals with your child's

  right to have its father's rights properly determined. If you decline to

  disclose the name and address of the biological father of your child,

  understand that you may be required to appear in court to explain your

  refusal and that your name may be used in connection with the

  publication of notice to the biological father. Understand that you are

  providing this affidavit under oath and that the information provided

  will be held in strict confidence and will be used only in connection

  with the adoption of your child.

  STATE OF GEORGIA

  COUNTY OF ____

  Personally appeared before me, the undersigned officer duly

  authorized to administer oaths, ____, who, after having been

  sworn, deposes and says as follows:

  That my name is ____.

  That I am the mother of a (male) (female) child born (insert name

  of child) in the State of ____, County of ____ on (insert birthdate

  of child).

  That I am ____ years of age, having been born in the State of

  ____, County of ____ on ____.

  That my social security account number is ____.

  That my marital status at the time of the conception of my child

  was (check the status and complete the appropriate information):

  ( ) Single, never having been married.

  ( ) Separated but not legally divorced; the name of my spouse

  is ____; his last known address is ____; we were married

  in the State of ____, County of ____ on ____; we have been

  separated since ____; we last had sexual relations on ____.

  ( ) Divorced; the name of my previous spouse is ____; we were

  married in the State of ____, County of ____ on ____; his last

  known address is ____; divorce granted in the State of

  ____, County of ____ on ____.

  ( ) Legally married; the name of my spouse (was) (is) ____;

  we were married in the State of ____, County of ____ on ____; and

  his last known address is ____.

  ( ) Married through common-law marriage relationship prior to

  January 1, 1997; the name of my spouse (was) (is) ____; his

  last known address is ____; our relationship began in the State

  of ____, County of ____ on ____.

  ( ) Widowed; the name of my deceased spouse was ____; we

  were married in the State of ____, County of ____ on ____;

  and he died on ____ in the County of ____, State of ____.

  That my name and marital status at the time of the birth of my

  child was (check the status and complete the appropriate information):

  Name

  ____

  ( ) Single, never having been married.

  ( ) Separated, but not legally divorced; the name of my spouse

  (was) (is) ____; his last known address is ____; we were

  married in the State of ____, County of ____ on ____; we

  have been separated since ____; we last had sexual relations on

  ____.

  ( ) Divorced; the name of my former spouse is ____; we were

  married in the State of ____, County of ____ on ____;

  his last known address is ____; divorce granted in the State

  of ____, County of ____.

  ( ) Legally Married; the name of my spouse (was) (is) ____;

  we were married in the State of ____, County of ____ on ____

  on ____; and his last known address is ____.

  ( ) Married through common-law relationship prior to January 1,

  1997; the name of my spouse (was) (is) ____; his last known

  address is ____; our relationship began in the State of ____,

  County of ____ on ____.

  ( ) Widowed; the name of my deceased spouse was ____; we were

  married in the State of ____, County of ____ on ____; and he

  died on ____ in the County of ____, State of ____.

  That the name of the biological father of my child is (complete

  appropriate response):

  Known to me and is (____ );

  Known to me but I expressly decline to identify him because

  ____; or

  Unknown to me because

  ____

  ____ .

  That the last known address of the biological father of my child

  is (complete appropriate response):

  Known to me and is ____;

  Known to me but I expressly decline to provide his address

  because ____; or

  Unknown to me because

  ____

  ____ .

  That, to the best of my knowledge, I (am) (am not) of American

  Indian heritage. If so:

  (A) The name of my American Indian tribe is ____ and the

  percentage of my American Indian blood is ____ percent.

  (B) My relatives with American Indian blood are:

  ____

  ____

  ____

  (C) I (am) (am not) a member of an American Indian tribe. If

  so, the name of the tribe is ____.

  (D) I (am) (am not) registered with an American Indian tribal

  registry. If so, the American Indian tribal registry is:

  ____ and my registration or identification number is:

  ____.

  (E) A member of my family (is) (is not) a member of an American

  Indian tribe. If so, the name of each such family member is:

  ____ and the name of the corresponding American Indian tribe

  is: ____.

  (F) A member of my family (is) (is not) registered with an

  American Indian tribal registry. If so, the name of each such

  family member is: ____ and the name of the corresponding

  American Indian tribal registry is: ____ and their

  corresponding registration or identification numbers are: ____.

  That to the best of my knowledge, the biological father (is) (is

  not) of American Indian heritage. If so:

  (A) The name of his American Indian tribe is ____ and the

  percentage of his American Indian blood is ____ percent.

  (B) His relatives with American Indian blood are:

  ____

  ____

  ____ .

  (C) He (is) (is not) a member of an American Indian tribe. If

  so, the name of the tribe is:____.

  (D) He (is) (is not) registered with an American Indian tribal

  registry. If so, the American Indian tribal registry is:

  ____ and his registration or identification number is:____ .

  That the date of birth of the biological father (was ____,

  ____) or (is not known to me).

  That the biological father (is) (is not) on active duty in a

  branch of the United States armed forces. If so:

  (A) The branch of his service is (Army) (Navy) (Marine) (Air

  Force) (Coast Guard).

  (B) His rank is ____.

  (C) His duty station is ____.

  If applicable, please provide any additional available

  information regarding his military service.

  ____

  ____

  ____ .

  That the biological father of my child, whether or not identified

  herein (strike each inappropriate phrase):

  (Was) (Was not) married to me at the time this child was

  conceived;

  (Was) (Was not) married to me at any time during my pregnancy

  with this child;

  (Was) (Was not) married to me at the time that this child was

  born;

  (Did) (Did not) marry me after the child was born and recognize

  the child as his own;

  (Has) (Has not) been determined to be the child's father by a

  final paternity order of a court;

  (Has) (Has not) legitimated the child by a final court order;

  (Has) (Has not) lived with the child;

  (Has) (Has not) contributed to its support;

  (Has) (Has not) provided for my support during my pregnancy or

  hospitalization for the birth of the child;

  (Has) (Has not) provided for my medical care during my

  pregnancy or hospitalization for the birth of the child; and

  (Has) (Has not) made any attempt to legitimate the child.

  That I have received or been promised the following financial

  assistance, either directly or indirectly, from whatever source, in

  connection with my pregnancy, the birth of my child, and its

  placement for adoption: ____.

  That I recognize that if I knowingly and willfully make a false

  statement in this affidavit, I will be guilty of the crime of false

  swearing.

  ____

  (Biological mother's signature)

  Sworn to and subscribed

  before me this ____

  day of ____, ____.

  ____

  Notary public (SEAL)

  My Commission Expires ____.

• (1) The affidavit shall set forth:
  • (A) Her name;
  • (B) Her relationship to the child;
  • (C) Her age;
  • (D) Her marital status;
  • (E) The name and last known address of any spouse at the time the child was adopted and whether any such spouse also adopted the child or was the biological father of the child;
  • (F) The circumstances surrounding her adoption of her child, including the date the adoption was finalized, the state and county where finalized, and the name and address of the adoption agency, if any; and
  • (G) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with the placement or arranging for the placement of her child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the adoptive mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the adoptive mother need only state the nature of the assistance received.

• (2) The affidavit shall be in substantially the following form:

  ADOPTIVE MOTHER'S AFFIDAVIT

  NOTICE TO MOTHER:

  This is an important legal document which deals with your child's

  right to have its legal father's rights properly terminated. Understand

  that you are providing this affidavit under oath and that the

  information provided will be held in strict confidence and will be used

  only in connection with the adoption of your child.

  STATE OF GEORGIA

  COUNTY OF ____

  Personally appeared before me, the undersigned officer duly

  authorized to administer oaths, ____, who, after having been sworn,

  deposes and says as follows:

  That my name is ____.

  That I am the adoptive mother of a (male) (female) child born (

  ____ ) in the State of ____, County of ____ on (

  ____ ).

  That I am ____ years of age, having been born in the State of

  ____, County of ____ on ____.

  That my marital status is (check the status and complete the

  appropriate information):

  ( ) Single, never having been married.

  ( ) Separated but not legally divorced; the name of my spouse

  is ____; his last known address is ____; we were married in

  the State of ____, County of ____ on ____; we have been

  separated since ____; my spouse (did) (did not) also adopt said

  child; my spouse (is) (is not) the biological father of said child.

  ( ) Divorced; the name of my previous spouse is ____; we

  were married in the State of ____, County of ____ on ____;

  his last known address is ____; divorce granted in the State

  of ____, County of ____ on ____; my previous spouse (did)

  (did not) also adopt said child; my previous spouse (is) (is not)

  the biological father of said child.

  ( ) Legally married; the name of my spouse is ____; we were

  married in the State of ____, County of ____ on ____; his

  last known address is ____; my spouse (did) (did not) also

  adopt said child; my spouse (is) (is not) the biological father of

  said child.

  ( ) Married through common-law marriage relationship; the name

  of my spouse is ____; his address is ____; the date and

  place our relationship began is ( ____ ); my spouse

  (did) (did not) also adopt said child; my spouse (is) (is not) the

  biological father of said child.

  ( ) Widowed; the name of my deceased spouse is ____; we

  were married in the State of ____, County of ____ on ____;

  he died on ____ in the County of ____, State of ____; he

  (did) (did not) also adopt said child; and he (was) (was not) the

  biological father of said child.

  That I adopted my child in the State of ____, County of ____;

  That the final order of adoption was entered on ____;

  That there (was) (was not) an adoption agency involved in the

  placement of my child with me for adoption; and if so its name was____,

  and its address is____ .

  That I have received or been promised the following financial

  assistance, either directly or indirectly, from whatever source, in

  connection with my child's placement for adoption:____ .

  That I recognize that if I knowingly and willfully make a false

  statement in this affidavit, I will be guilty of the crime of false

  swearing.

  ____

  (Adoptive mother)

  Sworn to and subscribed

  before me this ____

  day of ____, ____.

  ____

  Notary public

AFFIDAVIT OF AGENCY OR

DEPARTMENT REPRESENTATIVE

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, ____, who, after having been sworn, deposes and

says as follows:

That I am (position) of (department or agency).

That prior to the execution of the accompanying SURRENDER OF

RIGHTS/FINAL RELEASE FOR ADOPTION by ____, releasing and

surrendering all of (his) (her) rights in a (male) (female) minor child

born ( ____ ) on ( ____ ), I

reviewed with and explained to said individual all of the provisions of

the surrender, and particularly the provisions which provide that the

surrender is a full surrender of all rights to the child.

That based on my review and explanation to said individual, it is my

opinion that said individual knowingly, intentionally, freely, and

voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

____

(Agency representative)

Sworn to and subscribed

before me this ____

day of ____, ____.

____

Notary public

AFFIDAVIT OF PETITIONER'S REPRESENTATIVE

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, ____, who, after having been sworn, deposes and

says as follows:

That my name is____ .

That my address is____ .

That prior to the execution of the accompanying SURRENDER OF

RIGHTS/FINAL RELEASE FOR ADOPTION by ____, releasing and

surrendering all of (his) (her) rights in a (male) (female) minor child

born ( ____ ) on ( ____ ), I

reviewed with and explained to said individual all of the provisions of

the surrender, and particularly the provisions which provide that the

surrender is a full surrender of all rights to the child.

That based on my review and explanation to said individual, it is my

opinion that said individual knowingly, intentionally, freely, and

voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

____

(Petitioner's representative)

Sworn to and subscribed

before me this ____

day of ____, ____.

____

Notary public

PARENTAL CONSENT TO STEPPARENT ADOPTION

I, the undersigned, hereby consent that my spouse ( ____

____ ) adopt my (son) (daughter), ( ____ ), whose date of

birth is ____, and in so doing I in no way relinquish or surrender my

parental rights to the child.

I further acknowledge service of a copy of the petition for adoption of

the child as filed on behalf of my spouse, and I hereby consent to the

granting of the prayers of the petition. I also waive all other and further

service and notice of any kind and nature in connection with the

proceedings.

This ____ day of ____, ____.

____

(Parent)

____

Unofficial witness

____

Notary public