STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Original for Court Record In the Superior Court of the State of California in and for the County of ___________________________________ ******************** In the Matter of the Petition of * * * ________________________________ * Petitioner STEPPARENT ADOPTION Consent to Adoption by Parent Outside California in Armed Forces Giving Custody to Husband or Wife or Domestic Partner of Other Parent * I, the undersigned, being the parent of _______________________________________________________ Name of Minor do hereby give my full and free consent to the adoption of said child by ___________________________________________________________________________________________________ Name of Petitioner (Stepparent) the petitioner herein, it being fully understood by me that with the signing of this document my consent may not be withdrawn except with court approval, and that with the signing of the order of adoption by the court, I shall give up all my rights of custody, services, and earnings of said child, and that said child cannot be reclaimed by me. Said child was born on ________________________ in ______________________________________ and is Date Name of Natural Parent City and State Name of Natural Parent the child of ____________________________________ and ______________________________________________ Date _________________ 20 ___. _______________________________________________ Signature of Parent On this the _______ day of _______________, 20___, before me ___________________________________ , Name of Officer the undersigned officer, personally appeared ____________________________________________________ satisfactorily Name of Parent 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/she executed the same. And the undersigned does further certify that he/she is at the date of this certificate a commissioned officer in the active service of the armed forces of the United States having the general powers of a notary public under the provisions of Section 936 of Title 10 of the United States Code (Public Law 90-632). I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. _______________________________________________ _______________________________________________ SIGNATURE OF OFFICER AND SERIAL NUMBER, RANK, BRANCH OF SERVICE AND CAPACITY IN WHICH SIGNED NOTICE TO BIRTH PARENT WHO CONSENTS TO THE CHILD'S ADOPTION: If you or your child lived together at any time as parent and child, the adoption of your child by a stepparent does not affect the child's right to inherit your property or the property of blood relatives. For further information regarding this right of inheritance, you should consult an attorney at your own expense. * SEE REVERSE SIDE This form to be used only when parent is giving custody of child to husband/wife/domestic partner, as defined in Family Code Section 297, of other parent. Original for court record. AD 2D (3/08) American LegalNet, Inc. www.FormsWorkFlow.com Section 1183.5 of the Civil Code of California states in part: § 1183.5, Notarial acts Armed forces. Any officer on active duty or performing inactive-duty training in the armed forces having the general powers of a notary public pursuant to Section 936 or 1044a of Title 10 of the United States Code (Public Law 90-632 and 101-510) and any successor statutes may perform all notarial acts for any person serving in the armed forces of the United States, wherever he or she may be, or for any spouse of a person serving in the armed forces, wherever he or she may be, or for any person eligible for legal assistance under laws and regulations of the United States, wherever he or she may be, for any person serving with, employed by, or accompanying such armed forces outside the United States and outside the Canal Zone, Puerto Rico, Guam and the Virgin Islands, and any person subject to the Uniform Code of Military Justice outside of the United States. ********** AD 2D (3/08) American LegalNet, Inc. www.FormsWorkFlow.com