THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Surrender of Parental Rights over Case Number: (if known) SURRENDER OF PARENTAL RIGHTS Of: 1. Birth Mother Birth Father (RSA 170-B:5 through 170-B:12) Legal Father Name of parent surrendering rights Telephone City/town, state of residence Mailing Address Date of Birth 2. Place of Birth Attorney for surrendering parent Telephone Mailing Address 3. Name of other parent Telephone City/town, state of residence Mailing Address Date of Birth 4. Child Name Date of Birth 5. Place of Birth Place of Birth Is the child an Indian child as defined by the Indian Child Welfare Act? If yes, name and address of tribe Yes No Is tribe recognized by the federal government as eligible for federal services or certain Alaskan Yes No native corporations as defined in 43 U.S.C. §1602(c)? 6. Birth mother’s marital status: Single Married If married, divorced or widowed, name of spouse If applicable, date of marriage Divorced Widowed date of divorce 7. Do you know the identity of the adoptive parents? 8. Are there any pending adoption, juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimation, custody or other proceedings affecting minor or parents of this Yes No If yes, attach a separate sheet identifying and explaining each. minor? NHJB-2080-FP (10/01/2006) (formerly AOC-082S-003 and AOC-082S-008) Page 1 of 3 Yes No American LegalNet, Inc. www.FormsWorkflow.com Case Name: Surrender of Parental Rights over Case Number: SURRENDER OF PARENTAL RIGHTS Please read carefully or complete the information below before signing this document. By completing this surrender of parental rights, I understand that my parental rights over the child, including the rights of care, custody and control of the child, will cease when the court approves this surrender. I also waive any right to receive any notices about future hearings about the child. I understand that after the court approves this surrender, all my parental obligations will be extinguished, except the obligation to pay any accrued unpaid child support. I understand that after the court approves this surrender in compliance with New Hampshire law, the surrender is final, and may not be revoked or set aside for any reason, unless the court finds that the surrender was obtained by fraud or duress, and that the withdrawal of the surrender is in the best interests of the adoptee. The failure of an adoptive parent to comply with an arrangement or understanding reached with the birth parent with respect to the post-surrender exchange of identifying or non-identifying information, communication or contact is not a reason to revoke or set aside a surrender. I have been informed that child placing agencies duly licensed pursuant to RSA 170-E are available to counsel me about my decision to surrender my parental rights. I have been provided legal counsel, unless waived with approval of the court. I have not received or been promised any money or anything of value for the completion of this surrender, except for payments permissible under New Hampshire law. They are as follows: By signing this document below, I declare: h h h h h h that I am the parent of the above named child; that all the information on this surrender form is true; that I have read and understand the content of this document; that all of my questions have been answered by the court or its designee; that I wish this surrender of parental rights to take effect; and that (please check one of the following): I do not wish to receive confirmation of the final adoption of this child. I wish to receive confirmation of the final adoption of this child. Date Signature State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any NHJB-2080-FP (10/01/2006) (formerly AOC-082S-003 and AOC-082S-008) by Signature of Judge / Notarial Officer / Title Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case Name: Surrender of Parental Rights over Case Number: SURRENDER OF PARENTAL RIGHTS If the surrendering parent is a minor or under guardianship, complete the following section. We, , are the parents or guardians of the named birth parent who is surrendering his/her rights, and hereby give our assent to this surrender. Signature / Relationship Address Signature / Relationship Address State of , County of by This instrument was acknowledged before me on My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER This surrender of parental rights is: Date NHJB-2080-FP (10/01/2006) (formerly AOC-082S-003 and AOC-082S-008) Approved Not approved Judge Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com