STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES REFUSAL TO GIVE CONSENT TO ADOPTION Alleged Father INSTRUCTIONS: COUNTY Original: Court Record Copy: Parent Copy: Case Record 1. This form is to be completed by the alleged father who refuses to consent to the adoption of this child. 2. The alleged father must initial each statement and sign at the bottom of the form. 3. Complete Section A or B as explained on the second page. ACTION NUMBER I, _______________________________________________________________, having been alleged to be the father of NAME OF ALLEGED FATHER _______________________________________________________________________, (Gender: NAME OF CHILD I M I F), born to ___________________________________________________ on __________________________________, refuse to NAME OF MOTHER DATE OF BIRTH give my consent to the adoption of said child by _________________________________________________________. NAME OF PETITIONER(S) _______ I understand I have the right to retain a lawyer to assist me with this matter. INITIAL _______ I understand that by signing this form it does not stop the adoption. I understand that if I want to stop the adoption INITIAL I must take legal action as soon as possible. _______ I understand if I decide to establish my paternity of this child I must file an action under Family Code Section INITIAL 7630(c). I understand I must file an action within 30 days of being served with written notice of the alleged paternity and the proposed adoption or within 30 days of the birth of the child, whichever is later. _______ I understand that if I take no action the court may enter an order terminating my parental rights without further INITIAL notice to me. SIGNATURE OF ALLEGED FATHER DATE AD 20B (5/15) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES SECTION A COmplete if signed in California SIGNATURE OF AGENCY REPRESENTATIVE (CDSS or Delegated County Adoption Agency) DATE NAME OF AGENCY REPRESENTATIVE TITLE OF AGENCY REPRESENTATIVE NAME OF AGENCY (CDSS or Delegated County Adoption Agency) COUNTY WHERE SIGNED 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 20B (5/15) Page 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com