The ______________________________________________ (Agency Name) hereby states its
willingness to accept the attached relinquishment agreement as written and to
undertake custody of the child named in the agreement for the sole purpose of
placing said child in a suitable adoptive home.
I hereby execute this relinquishment agreement as
the duly authorized representative of _________________________________ (Agency) at ___________________________ (Place of Execution) on _____________ (Date).
Signature of Authorized Official of Agency Date