STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES PRESUMED FATHER'S CONSENT TO ADOPTION WHEN DENYING HE IS THE BIOLOGICAL FATHER (In or Out-of-California) COUNTY Original: Court Record Copy: Parent Copy: Case Record In the Matter of the Petition of ACTION NUMBER _________________________________________________ PETITIONER(S) I, __________________________________ , being presumed by law to be the father of __________________________ NAME OF PARENT NAME OF CHILD (Gender: M F ), born to __________________________________________________ on ______________________, NAME OF MOTHER DATE OF BIRTH in ___________________________________________________ declare that I am not the biological father of said child PLACE OF BIRTH and give my full and free consent to the adoption of said child by ___________________________________________. NAME OF PETITIONER(S) I understand that I may revoke this consent only during the thirty (30) day period beginning on the date I sign this consent and only if I have not waived my right to revoke the consent. I further understand 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 I may not reclaim said child. I declare I am not the biological father of said child and am executing this consent to adoption solely for the purpose of promoting the welfare and best interest of said child by facilitating said child's adoption by the petitioner(s). SIGNATURE OF PRESUMED FATHER DATE FULL ADDRESS SECTION A COmplete if Signed in California I, ______________________________________________, a representative of _________________________________________, NAME OF AGENCY REPRESENTATIVE NAME OF CDSS OR DELEGATED COUNTY ADOPTION AGENCY have witnessed the signing of this consent to adoption by the above-named parent on _________________________________ in DATE _________________________________________. COUNTY WHERE SIGNED SIGNATURE OF AGENCY REPRESENTATIVE TITLE OF AGENCY REPRESENTATIVE FULL ADDRESS TELEPHONE NUMBER SECTION B COmplete if Signed Outside of California* *** THIS FORM MUST BE SIGNED BY A NOTARY PUBLIC WHEN SIGNED OUTSIDE OF CALIFORNIA*** The Notary Public must staple the Acknowledgement document to this form and sign and date below. SIGNATURE OF NOTARY DATE *If signing outside the United States, this section must meet with the requirements of California Civil Code Section 1183 AD 165 (3/15) (combined with AD 166) American LegalNet, Inc. www.FormsWorkFlow.com