Department Of Health And Human Services Or Agency Surrender Or Parental Rights
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Department Of Health And Human Services Or Agency Surrender Or Parental Rights Form. This is a New Hampshire form and can be use in Probate Court Statewide.
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Tags: Department Of Health And Human Services Or Agency Surrender Or Parental Rights, NHJB-2081-FP, New Hampshire Statewide, Probate Court
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
DEPARTMENT OF HEALTH AND HUMAN SERVICES OR AGENCY
SURRENDER OF PARENTAL RIGHTS
(RSA 170-B:5 through 170-B:12)
1.
Name of agency surrendering rights
Executive head or authorized representative
Telephone
Email address
Mailing Address
2.
Name of Child
Date of birth
3.
Place of birth
Name of birth mother
Date of birth mother’s surrender or termination of parental rights (TPR)
Place of surrender or TPR
4.
Case number
Name of birth father
Date of birth father’s surrender or termination of parental rights (TPR)
Place of surrender or TPR
Case number
Please read carefully the information below before signing this document.
By completing this surrender of parental rights, I understand that my department or agency will continue to
have a legal relationship with the child, giving the department or agency responsibility for oversight of the
support, medical, and other care of the minor child until a final decree of adoption has been issued. I
understand that temporary care, custody and control of the child will be transferred to the adoptive parents
during this interlocutory period.
By signing this document below, I declare:
that I represent the department or agency having care, custody and control of the child;
that all the information on this surrender form is true;
that I have read and understand the content of this document; and
that I wish this surrender of parental rights to take effect.
Date
Signature of Executive Head or Authorized Representative
State of
, County of
This instrument was acknowledged before me on
by
My Commission Expires
Affix Seal, if any
Signature of Notarial Officer / Title
ORDER
This surrender of parental rights is:
Approved
Not approved
Date
Judge
NHJB-2081-FP (10/01/2006)
(formerly AOC-082SA-003)
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