STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY ORIGINAL FOR COURT RECORD CALIFORNIA DEPARTMENT OF SOCIAL SERVICES In the Superior Court of the State of California in and for the County of _______________________________ } In the Matter of the Petition of STEPPARENT ADOPTION Consent to Adoption by Parent Outside California Giving Custody to Husband or Wife or Domestic Partner of Other Parent _______________________________________ Petitioner I, the undersigned, being the parent of _______________________________________________________ do Name of Child hereby give my full and free consent to the adoption of said child by ______________________________________________________________________________________________ Name of Petitioner (Stepparent) the petitioner herein, it being fully understood by me that with the signing of this document my consent may not be withdrawn except with court approval, and that with the signing of the order of adoption by the court, I shall give up all my rights of custody, services, and earnings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. Said child was born on __________________ in ____________________________________________ and is Date City and State the child of _____________________________________ and ___________________________________________ . Name of Birth Parent Name of Birth Parent Date _________________________________ 20 ____. ______________________________________________ Signature of Parent STATE OF ______________________________ ) ) County of _______________________________ ) On _________________________________ before me, __________________________________ , a Notary Public, personally appeared ________________________________ proved to me on the basis of satisfactory evidence to Name of Parent 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, or the entity upon behalf of which the person acted, 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. ____________________________________________ (Seal) Signature NOTICE TO THE BIRTH PARENT WHO CONSENTS TO THE CHILD’S ADOPTION: If you or your child lived together at any time as parent and child, the adoption of your child by a stepparent does not affect the child’s right to inherit your property or the property of blood relatives. For further information regarding this right of inheritance, you should consult an attorney at your own expense. This form to be used only when parent is giving custody of the child to the husband or wife or domestic partner, as defined in Family Code Section 297, of other parent. Original for court record. AD 2B (3/08) American LegalNet, Inc. www.FormsWorkflow.com