RELINQUISHMENT OF CHILD TO AGENCY BY MOTHER
I, __________________________, of
______________________________ (Address),
am the mother of ________________________________________, a _____________ (Male or Female) minor child born on
____________ (Date), in
__________ (City),
_______________ (State). I am the parent who has sole custody of such
minor child, and the child is indigent, destitute, and homeless. I am financially unable to support the
child, and both the child and I have been deserted and abandoned by the father
of the child. I do not know the
father's present whereabouts.
I believe that the welfare of my child will be
promoted by placement in a good home, and in consideration of the promise of
_______________________________________ (Licensed
Adoption Agency) to place my child, I do hereby voluntarily,
unconditionally, and not acting under any coercion, surrender to
________________________________ (Name of
Adoption Agency) my minor child, _________________________________,
expressly giving and granting to ____________________________________________ (Name of Adoption Agency) full power in its
discretion to place the child in adoption and to consent to such adoption
without further notice to me, in all respects and in the same manner as if I
personally gave such consent at the time of adoption.
I do further consent that
___________________________ (Name of
Adoption Agency) shall have full care and custody of my minor child
until _________ (he or she) shall
be placed in a home for adoption, and that
______________________________________ (Name
of Adoption Agency) alone has the power to exercise control over my
minor child until such time as a legal adoption shall be consummated.
I do further agree not to interfere with the custody
or management of my minor child in any way from the date of this instrument and
not to encourage or permit anyone else to do so.
In witness whereof, I have executed this instrument
at __________________________ (Designate
Place of Execution) on ____________ (Date).
____________________________________ _______________
Signature Date
