STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES Original for Court Record Certified Copy for State Department of Social Services IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF_____________________ In the Matter of the Petition of ______________________ Petitioner } Date STEPPARENT ADOPTION Consent to Adoption by Parent Retaining Custody I, the undersigned, being the parent of _________________________________________________________ give my full and Name of Minor free consent to the adoption of said child by _________________________________________________________________ , who is Name of Petitioner (Stepparent) my husband/wife/domestic partner without relinquishing any of my rights, duties, obligations as his/her parent, and I respectfully ask that the petition be granted. Said child was born on __________________________________ in ___________________________________and is the child City and State of __________________________________________________________and __________________________________________________________ Name of Legal Parent Name of Legal Parent Date_________________________ 20 ______ _________________________________________________ Signature of Parent Signed in the presence of ___________________________________ *Title * The Clerk of the Superior Court, the Probation Officer, or, where stepparent investigations are delegated to County Welfare Departments, a County Welfare Department Staff member may witness. This form for use only when person giving consent is husband or wife of petitioner or domestic partner, as defined in Family Code Section 297, of petitioner. Original for court record, certified copy to be sent immediately to California Department of Social Services, Sacramento. AD 2 (6/02) American LegalNet, Inc. www.FormsWorkFlow.com