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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).




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Signature                                                                                                                           Date

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