Rev. 07/2018 KSJC 1 RELINQUISHMENT OF MINOR CHILD TO AGENCY NOTICE TO PARENT OR PERSON IN LOCO PARENTIS: This is an important legal document and by signing it you are permanently giving up all custody and other parental rights to the child named in this relinquishment. You are to receive a copy of this document. I, (name) , (mother, father, person in loco parentis) of , a minor child, state: 1. The child was born on (date of birth) at (place of birth) at .m. 2. I reside at , County of and State of . [My social security number is XX-XXXX- .] 3. I am years of age and was born in (year) . 4. [As required by law, as a minor I have been advised by independent legal counsel of the consequences of signing this relinquishment, and counsel was present when I signed it.] 5. I relinquish the child to (name of agency) , which I understand will have full power and all the rights of a birth parent or legal guardian over the child, including the power to place the child for adoption and give consent to the adoption. 6. I wish to and understand that by signing this relinquishment I do permanently give up all custody and other parental rights I have to the child. 7. [I (was married to ) (was not married) at the time of the child222s (conception)(birth).] [The father of the child is , whose present address is .] [There are no other possible fathers.] [ was determined to be the child222s father in District Court, case number .] [There is more than one possible father.] [The names and addresses of the possible fathers are: .] [The names and addresses of the possible fathers will be provided by separate affidavit.] American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/2018 KSJC 2 8. [To the best of my knowledge, neither the child nor I am a member of or eligible for membership in an Indian tribe recognized by federal law.] [To the best of my knowledge, the (father)(mother) is not a member of or eligible for membership in an Indian tribe recognized by federal law.] [I am a member of the tribe, (address) .] [The child is a member of the tribe, (address) .] [The (father) (mother) is a member of the tribe, (address) .] 9. [I freely and voluntarily enter my appearance in any proceeding instituted in any court of competent jurisdiction for the adoption of the child. I choose (to receive) (not to receive) notice of the time, date and location of the final hearing. If I have chosen to receive notice, I request that the notice of final hearing be sent to me at the following address by regular mail at least 10 days prior to the hearing: .] 10. I am of sound mind and under no undue restraint or duress. I have read and understand the above and I am signing it as my free and voluntary act. Dated , at .m. (signature of parent) [Must be acknowledged before either a judge or a notary public. Choose the appropriate acknowledgment from the two options below.] ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT STATE OF ) ) COUNTY OF ) I, , Judge of (name and location of court) certify that , known to me to be the same person whose name is signed on this relinquishment, appeared before me this day in person and acknowledged that (she)(he) signed this relinquishment as (her)(his) free and voluntary act, for the specified purpose. I have fully explained that by signing this relinquishment (she)(he) is permanently giving up all parental rights to the child and (she)(he) has stated that such is (her)(his) intention and desire. Dated , at .m. (signature of judge) American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/2018 KSJC 3 ACKNOWLEDGMENT BEFORE NOTARIAL OFFICER STATE OF ) ) COUNTY OF ) This relinquishment was acknowledged before me on ( date ) at ( time ) by ( name of person ). (signature of notarial officer) (SEAL, if any) title (and rank) [My Appointment Expires: ] ACCEPTANCE OF CHILD BY AGENCY I, , the undersigned, on behalf of (name of agency) , accept custody of , the above relinquished minor child. Date (signature and title) CERTIFICATE OF ATTORNEY FOR RELINQUISHING [MINOR] PARENT I am a licensed attorney representing , [who is a minor]. I have fully explained that by signing this relinquishment is permanently giving up all parental rights to the child and (she)(he) has stated that such is (her)(his) intention and desire. I was present at the execution of this relinquishment. Date (signature of attorney) Authority: K.S.A. 59-2143. American LegalNet, Inc. www.FormsWorkFlow.com