REVOCATION OF RELINQUISHMENT

 

 

On _______________ (Date), _____________________, the ________________ (Father/Mother) of _______________________, a minor ___________ (Male/Female) child, relinquished custody of said child to the _______________________________ (Name of Agency) located at ______________________________________________ (Address), in order that the above-named agency might place __________ (Him/Her) with suitable adoptive parents.

 

The ______________________ (Name of Agency) and ________________________, the ______________ (Father/Mother) of _______________________, the minor ___________ (Male/Female) child, now desire to revoke the agreement relinquishing custody of the child.

 

Thereupon, both parties consent to revoke the agreement to relinquish custody of the above-named minor child and to declare the agreement to be void and of no further effect.

 

_______________________________________                                 _________________

Signature of Parent                                                                                                          Date

 

______________ (Father/ Mother) of _________________________ (Name of Child)

 

____________________________________________ (Name and Address of Agency)

 

_________________________________________                            _________________

Signature and Title of Agency Official                                                         Date