STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REFUSAL TO GIVE PARENTAL CONSENT TO ADOPTION (Birth Mother/Presumed/Biological Father/Legal Parent) INSTRUCTIONS: COUNTY: Original: Copy: Copy: Court Record Parent Case Record 1. 2. 3. This form is to be completed by the legal parent who refuses to consent to the adoption of his/her child. The legal parent must initial each statement and sign at the bottom of the form. Complete Section A or B as explained below. ACTION NUMBER: I, ______________________________________________________________________________ being the (Choose One): NAME OF LEGAL PARENT I Birth Mother I Presumed Father I Biological Father I Other Legal Parent __________________________________ of ________________________________________________________ (Gender: I M I F) born on __________________ NAME OF CHILD DATE OF BIRTH refuse to give my consent to adoption of said child by _________________________________________________________. NAME OF PETITIONER(S) ________ INITIAL ________ INITIAL I understand I have the right to retain a lawyer to assist me with this matter. I understand that by signing this form it does not stop the adoption. I understand that if I want to stop the adoption I must take legal action as soon as possible. I understand that the petitioner(s) can go to court and ask the court to end my rights as this child's parent. DATE ________ INITIAL SIGNATURE OF LEGAL PARENT SECTION A Complete if signed in California SIGNATURE OF AGENCY REPRESENTATIVE (CDSS or Delegated County Adoption Agency) DATE NAME OF AGENCY REPRESENTATIVE TELEPHONE NUMBER NAME OF AGENCY (CDSS or Delegated County Adoption Agency) COUNTY WHERE SIGNED FULL ADDRESS SECTION B Complete if signed Outside-of-California* ***THIS FORM MUST BE WITNESSED 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 20 (ENG/SP) (4/15) American LegalNet, Inc. www.FormsWorkFlow.com