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Back to Forms for 'Adoptions'.




I, _______________________________, (name of parent) residing at _____________

________________________________________ (address), do hereby relinquish and forever release to ___________________________, (name) residing at ____________

___________________________________ (address), all my rights and responsibilities as parent to my _____________ (male/female) child ___________________________ (name), born at _________________________________________________________ (hospital or clinic name and address) on __________________ (month & day), ______ (year), which said child was born out of wedlock. 


I hereby assert that I am the natural mother of the above-named child, who has reached the age of _______________ (_____) days, and that I relinquish unto the above-named __________________________________ (name), all my rights and privileges to said child, and, therefore, I respectfully request any court of competent jurisdiction to enter its order of adoption.


This release is made pursuant to _________________ (cite statute or other authority).


In witness whereof, I have signed this instrument at ____________________________ (place of execution) on _____________________ (month & day), ________ (year).





This document was hereby signed in the presence of the following:


______________________________________                 __________________

______________________________________                 __________________

(Signature(s))                                                                                     (Date(s))

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