CERTIFICATE OF RELINQUISHMENT
This certifies that the attached document, executed
on ____________(Date), by
_____________________________ (Name)
of _____________________________ __________________________________ (Address), relinquishing custody of the
child named _________________________
(Name), to _____________________________, an agency authorized to
place children for adoption in a suitable home, was executed in accordance with
the laws of ___________________________ (State/Commonwealth);
and that the above-named child was placed for adoption with
_____________________ _____________________________ (Name/Names), of _________________________
_____________________________________________ (Address),
who ____________ (Has/Have) filed
a petition to formally adopt the above-named child in the Court of
_____________________________________________ (Name
and Address of Court).
Approval is hereby granted for completion of the
above-referenced adoption.
In witness whereof, I have signed this instrument in
my capacity as the duly authorized representative of
________________________________________
(Agency).
________________________________________ _____________
Signature and title of agency official Date
