STATE OF CALIFORNIA -- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES PARENTAL CONSENT TO ADOPTION (In or Out-of-California) COUNTY Original: Court Record Copy: Parent Copy: Case Record In the Matter of the Petition of ACTION NUMBER PETITIONER(S) I, ________________________________________________________________________________ being the (Choose One): NAME OF 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 in ___________________________________________________ give my full and free consent to the adoption of said child by PLACE OF BIRTH ____________________________________________________________________________________, NAME(S) OF PETITIONER(S) I understand that I may revoke this consent ONLY DURING THE THIRTY (30) DAY PERIOD beginning on the date I sign this consent and ONLY IF I HAVE NOT WAIVED MY RIGHT TO REVOKE THE CONSENT. I further understand that with the signing of the order of adoption by the court I shall give up all rights of custody, services, and earnings of said child and I may not reclaim said child. SIGNATURE OF PARENT DATE FULL ADDRESS SECTION A Complete If Signed In California I, ________________________________________________, a representative of ___________________________________ NAME OF AGENCY REPRESENTATIVE NAME OF CDSS OR DELEGATED COUNTY ADOPTION AGENCY have witnessed the signing of this consent to adoption by the above named parent on ______________________________ in DATE _________________________________________________. COUNTY WHERE SIGNED SIGNATURE OF AGENCY REPRESENTATIVE TITLE OF AGENCY REPRESENTATIVE 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 the requirements of California Civil Code Section 1183 AD 1A (Combined with AD 1C (4/15) American LegalNet, Inc. www.FormsWorkFlow.com