ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (NAME): FAX NO: (Optional) AMADOR COUNTY SUPERIOR COURT 500 ARGONAUT LANE JACKSON, CA 95642 (209) 257-2600 PETITIONER: CONSENT TO ADOPTION BY PARENT IN/OUTSIDE CALIFORNIA GIVING CUSTODY TO HUSBAND OR WIFE OF OTHER PARENT CASE NUMBER: I, the undersigned, being the father/mother of __________________________________________________ do hereby give my full and free consent to the adoption of said child by: _________________________________________(name of petitioner) the petitioner herein, it being fully understood by me that with the signing of this document my consent may not be withdrawn except with court approval, and that with the signing of the order of adoption by the court, I shall give up all my rights of custody, services, and earnings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 that said child cannot be reclaimed by me. Further, if I and my child lived together at any time as parents and child, the adoption of this child by a stepparent does not affect the child's right to inherit my property or the property of other blood relatives. Said child was born on ________________________________(date) in ______________________________________ (city and state) And is the child of __________________________________ and ____________________________________________ Date:______________________________ ________________________________________________ Signature of parent Signed in the present of: ____________________________________, Title: _________________________________________________________________ *A notary public, court clerk, probation officer, qualified court investigator or county welfare department staff member or any county of California may witness this consent. (CFC 9003(a)) Notary must affix acknowledgment FOR USE BY NOTARY PUBLIC ONLY State of California, County of Amador) On ______________________ before me ____________________________________________ personally appeared: (NAME OF NOTARY) ______________________________________________who provided me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person executed the instrument. I certify, under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature _____________________________________ (seal) Approved for Optional Use New 03/13/2017 CONSENT TO ADOPTION BY PARENT IN/OUTSIDE CALIFORNIA GIVING CUSTODY TO HUSBAND OR WIFE OF OTHER PARENT American LegalNet, Inc. www.FormsWorkFlow.com WWW.AMADORCOURT FCA-203