2010 Georgia Code
TITLE 19 - DOMESTIC RELATIONS
CHAPTER 8 - ADOPTION
ARTICLE 1 - GENERAL PROVISIONS
§ 19-8-26 - How surrender of parental rights executed; how and when surrender may be withdrawn; forms
O.C.G.A.
19-8-26 (2010)
19-8-26. How surrender of parental rights executed; how and when surrender may be withdrawn; forms
(a) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section
19-8-4 shall conform substantially to the following form:
SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO PARENT OR GUARDIAN:
This is an important legal document and by signing it you are
surrendering all of your right, title, and claim to the child identified
herein, so as to facilitate the child's placement for adoption. You are to
receive a copy of this document and as explained below have the right to
withdraw your surrender within ten days from the date you sign it.
---------------------
I, the undersigned, being solicitous that my (male) (female) child, born (
insert name of child ) on ( insert birthdate of child ), should receive the
benefits and advantages of a good home, to the end that (she) (he) may be
fitted for the requirements of life, consent to this surrender.
I, the undersigned, ( insert relationship to child ) of the aforesaid
child, do hereby surrender the child to ( insert name of child-placing
agency or Department of Human Services, as applicable ) and promise not to
interfere in the management of the child in any respect whatever; and, in
consideration of the benefits guaranteed by ( insert name of child-placing
agency or Department of Human Services, as applicable ) in thus providing
for the child, I do relinquish all right, title, and claim to the child
herein named, it being my wish, intent, and purpose to relinquish
absolutely all parental control over the child.
Furthermore, I hereby agree that the ( insert name of child-placing
agency or Department of Human Services, as applicable ) may seek for the
child a legal adoption by such person or persons as may be chosen by the (
insert name of child-placing agency or Department of Human Services, as
applicable ) or its authorized agents, without further notice to me. I do,
furthermore, expressly waive any other notice or service in any of the
legal proceedings for the adoption of the child.
Furthermore, I understand that under Georgia law the Department of Human
Services or the child-placing agency is required to conduct an
investigation and render a report to the court in connection with the legal
proceeding for the legal adoption of the child and I hereby agree to
cooperate fully with such department or agency in the conduct of its
investigation.
Furthermore, I hereby certify that I have received a copy of this
document and that I understand I may only withdraw this surrender by giving
written notice, delivered in person or mailed by registered mail or
statutory overnight delivery, to ( insert name and address of child-placing
agency or Department of Human Services, as applicable ) within ten days
from the date hereof; that the ten days shall be counted consecutively
beginning with the day immediately following the date hereof; however, if
the tenth day falls on a Saturday, Sunday, or legal holiday then the last
day on which the surrender may be withdrawn shall be the next day that is
not a Saturday, Sunday, or legal holiday; and I understand that it may NOT
be withdrawn thereafter.
Furthermore, I hereby certify that I have not been subjected to any
duress or undue pressure in the execution of this surrender document and do
so freely and voluntarily.
Witness my hand and seal this day of , .
(SEAL)
(Parent or guardian)
Unofficial witness
Notary public
(b) Reserved.
(c) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section
19-8-5 shall conform substantially to the following form:
SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO PARENT OR GUARDIAN:
This is an important legal document and by signing it you are
surrendering all of your right, title, and claim to the child identified
herein, so as to facilitate the child's placement for adoption. You are to
receive a copy of this document and as explained below have the right to
withdraw your surrender within ten days from the date you sign it.
---------------------
I, the undersigned, being solicitous that my (male) (female) child, born (
insert name of child ), on ( insert birthdate of child ), should receive
the benefits and advantages of a good home, to the end that (she) (he) may
be fitted for the requirements of life, consent to this surrender.
I, the undersigned, ( insert relationship to child ) of the aforesaid
child, do hereby surrender the child to ( insert name, surname not
required, of each person to whom surrender is made ), PROVIDED each such
person is named as petitioner in a petition for adoption of the child filed
in accordance with Article 1 of Chapter 8 of Title 19 of the Official Code
of Georgia Annotated within 60 days from the date hereof. Furthermore, I
promise not to interfere in the management of the child in any respect
whatever; and, in consideration of the benefits guaranteed by ( insert
name, surname not required, of each person to whom surrender is made ) in
thus providing for the child, I do relinquish all right, title, and claim
to the child herein named, it being my wish, intent, and purpose to
relinquish absolutely all parental control over the child.
It is also my wish, intent, and purpose that if each such person is not
named as petitioner in a petition for adoption as provided for above within
the 60 day period, other than for excusable neglect, or, if said petition
for adoption is filed within 60 days but the adoption action is dismissed
with prejudice or otherwise concluded without an order declaring the child
to be the adopted child of each such person, then I do hereby surrender the
child as follows:
(Mark one of the following as chosen)
I wish the child returned to me, and I expressly acknowledge that this
provision applies only to the limited circumstance that the child is not
adopted by the person or persons designated herein and further that this
provision does not impair the validity, absolute finality, or totality
of this surrender under any circumstance other than the failure of the
designated person or persons to adopt the child and that no other
provision of this surrender impairs the validity, absolute finality, or
totality of this surrender once the revocation period has elapsed; or
I surrender the child to ( insert name of designated licensed
child-placing agency ), a licensed child-placing agency, for placement
for adoption; or
I surrender the child to the Department of Human Services, as provided
by subsection (k) of Code Section
19-8-5, for placement for adoption;
and ( insert name of designated licensed child-placing agency ) or the
Department of Human Services may petition the superior court for custody
of the child in accordance with the terms of this surrender.
Furthermore, I hereby agree that the child is to be adopted either by
each person named above or by any other such person as may be chosen by the
( insert name of designated licensed child-placing agency ) or the
Department of Human Services and I do expressly waive any other notice or
service in any of the legal proceedings for the adoption of the child.
Furthermore, I understand that under Georgia law an agent appointed by
the court is required to conduct an investigation and render a report to
the court in connection with the legal proceeding for the legal adoption of
the child and I hereby agree to cooperate fully with such agent in the
conduct of this investigation.
Furthermore, I hereby certify that I have received a copy of this
document and that I understand I may only withdraw this surrender by giving
written notice, delivered in person or mailed by registered mail or
statutory overnight delivery, to ( insert name and address of agent of each
person to whom surrender is made ) within ten days from the date hereof;
that the ten days shall be counted consecutively beginning with the day
immediately following the date hereof; however, if the tenth day falls on a
Saturday, Sunday, or legal holiday then the last day on which the surrender
may be withdrawn shall be the next day that is not a Saturday, Sunday, or
legal holiday; and I understand that it may NOT be withdrawn thereafter.
Furthermore, I hereby certify that I have not been subjected to any
duress or undue pressure in the execution of this surrender document and do
so freely and voluntarily.
Witness my hand and seal this day of , .
(SEAL)
(Parent or guardian)
Unofficial witness
Sworn to and subscribed
before me this
day of , .
Notary public (SEAL)
My commission expires .
(d) The surrender of rights by a biological father who is not the legal father of the child pursuant to paragraph (2) of subsection (e) of Code Section
19-8-4,
19-8-5,
19-8-6, or
19-8-7 shall conform substantially to the following form:
SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO ALLEGED BIOLOGICAL FATHER:
This is an important legal document and by signing it you are
surrendering all of your right, title, and claim to the child identified
herein, so as to facilitate the child's placement for adoption. You are to
receive a copy of this document and as explained below have the right to
withdraw your surrender within ten days from the date you sign it.
---------------------
I, the undersigned, alleged biological father of a (male) (female)
child, born ( insert name of child ) to ( insert name of mother ) on (
insert birthdate of child ), being solicitous that said child should
receive the benefits and advantages of a good home, to the end that (she)
(he) may be fitted for the requirements of life, consent to this surrender.
I, the undersigned, do hereby surrender the child. I promise not to
interfere in the management of the child in any respect whatever; and, in
consideration of the benefits provided to the child through adoption, I do
relinquish all right, title, and claim to the child herein named, it being
my wish, intent, and purpose to relinquish absolutely all control over the
child.
Furthermore, I hereby agree that the child is to be adopted and I do
expressly waive any other notice or service in any of the legal proceedings
for the adoption of the child.
Furthermore, I understand that under Georgia law an agent appointed by
the court is required to conduct an investigation and render a report to
the court in connection with the legal proceeding for the legal adoption of
the child and I hereby agree to cooperate fully with the agent appointed by
the court in the conduct of this investigation.
Furthermore, I hereby certify that I have received a copy of this
document and that I understand I may only withdraw this surrender by giving
written notice, delivered in person or mailed by registered mail or
statutory overnight delivery, to ( insert name and address of child-placing
agency representative, Department of Human Services representative, person
to whom surrender is made, or petitioner's representative, as appropriate )
within ten days from the date hereof; that the ten days shall be counted
consecutively beginning with the day immediately following the date hereof;
however, if the tenth day falls on a Saturday, Sunday, or legal holiday
then the last day on which the surrender may be withdrawn shall be the next
day that is not a Saturday, Sunday, or legal holiday; and I understand that
it may NOT be withdrawn thereafter.
Furthermore, I hereby certify that I have not been subjected to any
duress or undue pressure in the execution of this surrender document and do
so freely and voluntarily.
Witness my hand and seal this day of , .
(SEAL)
(Alleged biological father)
Unofficial witness
Sworn to and subscribed
before me this
day of , .
Notary public (SEAL)
My commission expires .
(e) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section
19-8-6 or
19-8-7 shall conform substantially to the following form:
SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO PARENT OR GUARDIAN:
This is an important legal document and by signing it you are
surrendering all of your right, title, and claim to the child identified
herein, so as to facilitate the child's placement for adoption. You are to
receive a copy of this document and as explained below have the right to
withdraw your surrender within ten days from the date you sign it.
---------------------
I, the undersigned, being solicitous that my (male) (female) child, born
( insert name of child ), on ( insert birthdate of child ), should receive
the benefits and advantages of a good home, to the end that (she) (he) may
be fitted for the requirements of life, consent to this surrender.
I, the undersigned, ( insert relationship to child ) of the aforesaid
child, do hereby surrender the child to ( insert name of each person to
whom surrender is made ) and promise not to interfere in the management of
the child in any respect whatever; and, in consideration of the benefits
guaranteed by ( insert name of each person to whom surrender is made ) in
thus providing for the child, I do relinquish all right, title, and claim
to the child herein named, it being my wish, intent, and purpose to
relinquish absolutely all parental control over the child.
Furthermore, I hereby agree that ( insert name of each person to whom
surrender is made ) may initiate legal proceedings for the legal adoption
of the child without further notice to me. I do, furthermore, expressly
waive any other notice or service in any of the legal proceedings for the
adoption of the child.
Furthermore, I understand that under Georgia law the Department of Human
Services may be required to conduct an investigation and render a report to
the court in connection with the legal proceeding for the legal adoption of
the child and I hereby agree to cooperate fully with the department in the
conduct of its investigation.
Furthermore, I hereby certify that I have received a copy of this
document and that I understand I may only withdraw this surrender by giving
written notice, delivered in person or mailed by registered mail or
statutory overnight delivery, to ( insert name and address of each person
to whom surrender is made ) within ten days from the date hereof; that the
ten days shall be counted consecutively beginning with the day immediately
following the date hereof; however, if the tenth day falls on a Saturday,
Sunday, or legal holiday then the last day on which the surrender may be
withdrawn shall be the next day that is not a Saturday, Sunday, or legal
holiday; and I understand it may NOT be withdrawn thereafter.
Furthermore, I hereby certify that I have not been subjected to any
duress or undue pressure in the execution of this surrender document and do
so freely and voluntarily.
Witness my hand and seal this day of , .
(SEAL)
(Parent or guardian)
Unofficial witness
Notary public
(f) The pre-birth surrender of rights by a biological father who is not the legal father of the child pursuant to paragraph (3) of subsection (e) of Code Section
19-8-4,
19-8-5, or
19-8-7 shall conform substantially to the following form:
PRE-BIRTH SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO ALLEGED BIOLOGICAL FATHER
This is an important legal document and by signing it you are surrendering any and all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You have the right to wait to execute a Surrender of Rights Final Release for Adoption after the child is born, but by signing this document you are electing to surrender your rights prior to the birth of this child. You are to receive a copy of this document and as explained below have the right to withdraw your pre-birth surrender within ten days from the date you sign it.
---------------------
I, the undersigned, understand that I have been named by , the mother of the child expected to be born in (city) (county) (state) on or about the day of (month), (year), as the biological father or possible biological father of her child. I further understand that the mother wishes to place this child for adoption.
To the best of my knowledge and belief, the child has not been born as of the date I am signing this pre-birth surrender; however, if in fact the child has been born, this surrender shall have the same effect as if it were a surrender executed following the birth of the child.
I understand that by signing this document I am not admitting that I am the biological father of this child, but if I am, I hereby agree that adoption is in this child's best interest. I consent to adoption of this child by any person chosen by the child's mother or by any public or private child-placing agency without further notice to me. I expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.
I understand that I have the option to wait until after the child is born to execute a surrender of my rights (with a corresponding ten-day right of withdrawal) and, further, that by executing this document I am electing instead to surrender my rights before the child's birth.
I further understand that execution of this document does not fully and finally terminate my responsibilities until a final order of adoption is entered. I understand that if the child is not adopted, legal proceedings can be brought to establish paternity, and I may become liable for financial obligations related to the birth and support of this child.
Furthermore, I hereby certify that I have received a copy of this document and that I understand that I may only withdraw this pre-birth surrender by giving written notice, delivered in person or by statutory overnight delivery or registered mail, return receipt requested, to within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof; that, however, if the tenth day falls on a Saturday, Sunday, or legal holiday, then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and that it may NOT be withdrawn thereafter.
If prior to my signing this pre-birth surrender I have registered on Georgia's putative father registry then if I do not withdraw this surrender within the time permitted, I waive the notice I would be entitled to receive pursuant to the provisions of Code Section
19-8-12 of the Official Code of Georgia Annotated because of my registration on the putative father registry.
Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and do so freely and voluntarily.
Witness my hand and seal this day of , .
(SEAL)
Alleged biological father
Unofficial Witness
Sworn to and subscribed
before me on this day of
, .
Notary Public
Seal
My commission expires: .
(g) The acknowledgment of surrender of rights pursuant to subsection (f) of Code Section
19-8-4,
19-8-5,
19-8-6, or
19-8-7 shall conform substantially to the following form:
ACKNOWLEDGMENT OF SURRENDER
OF RIGHTS
By execution of this paragraph, the undersigned expressly acknowledges:
(A) That I have read the accompanying SURRENDER OF RIGHTS/FINAL
RELEASE FOR ADOPTION relating to said minor child born ( insert name of
child ), a (male) (female) on ( insert birthdate of child );
(B) That I understand that this is a full, final, and complete
surrender, release, and termination of all of my rights to the child;
(C) That I have the unconditional right to revoke the surrender by
giving written notice, delivered in person or mailed by registered mail
or statutory overnight delivery, to ( insert name and address of each
person or entity to whom surrender is made ) not later than ten days
from the date of the surrender and that after such ten-day period I
shall have no right to revoke the surrender;
(D) That the ten days shall be counted consecutively beginning with
the day immediately following the date the surrender is executed;
however, if the tenth day falls on a Saturday, Sunday, or legal holiday
then the last day on which the surrender may be withdrawn shall be the
next day that is not a Saturday, Sunday, or legal holiday;
(E) That I have read the accompanying surrender and received a copy
thereof;
(F) That any and all questions regarding the effect of said surrender
and its provisions have been satisfactorily explained to me;
(G) That I have been afforded an opportunity to consult with counsel
of my choice prior to execution of the surrender; and
(H) That the surrender of my rights has been knowingly,
intentionally, freely, and voluntarily made by me.
Witness my hand and seal this day of , .
(SEAL)
(Parent, guardian, or biological father)
Unofficial witness
Notary public
(h) The affidavit of a legal mother required by subsection (g) of Code Section
19-8-4,
19-8-5,
19-8-6, or
19-8-7 shall meet the following requirements:
(1) The affidavit shall set forth:
(A) Her name;
(B) Her relationship to the child;
(C) Her age;
(D) Her marital status;
(E) The identity and last known address of any spouse or former spouse;
(F) The identity, last known address, and relationship to the mother of the biological father of her child, provided that the mother shall have the right not to disclose the name and address of the biological father of her child should she so desire;
(G) Whether or not the biological father of the child has lived with the child, contributed to its support, provided for the mother's support or medical care during her pregnancy or during her hospitalization for the birth of the child, or made an attempt to legitimate the child; and
(H) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of the child, or the placement or arranging for the placement of the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the mother need only state the nature of the assistance received; and
(2) The affidavit shall conform substantially to the following form:
MOTHER'S AFFIDAVIT
NOTICE TO MOTHER:
This is an important legal document which deals with your child's
right to have its father's rights properly determined. If you decline to
disclose the name and address of the biological father of your child,
understand that you may be required to appear in court to explain your
refusal and that your name may be used in connection with the
publication of notice to the biological father. Understand that you are
providing this affidavit under oath and that the information provided
will be held in strict confidence and will be used only in connection
with the adoption of your child.
STATE OF GEORGIA
COUNTY OF
Personally appeared before me, the undersigned officer duly
authorized to administer oaths, , who, after having been
sworn, deposes and says as follows:
That my name is .
That I am the mother of a (male) (female) child born (insert name
of child) in the State of , County of on (insert birthdate
of child).
That I am years of age, having been born in the State of
, County of on .
That my social security account number is .
That my marital status at the time of the conception of my child
was (check the status and complete the appropriate information):
( ) Single, never having been married.
( ) Separated but not legally divorced; the name of my spouse
is ; his last known address is ; we were married
in the State of , County of on ; we have been
separated since ; we last had sexual relations on .
( ) Divorced; the name of my previous spouse is ; we were
married in the State of , County of on ; his last
known address is ; divorce granted in the State of
, County of on .
( ) Legally married; the name of my spouse (was) (is) ;
we were married in the State of , County of on ; and
his last known address is .
( ) Married through common-law marriage relationship prior to
January 1, 1997; the name of my spouse (was) (is) ; his
last known address is ; our relationship began in the State
of , County of on .
( ) Widowed; the name of my deceased spouse was ; we
were married in the State of , County of on ;
and he died on in the County of , State of .
That my name and marital status at the time of the birth of my
child was (check the status and complete the appropriate information):
Name
( ) Single, never having been married.
( ) Separated, but not legally divorced; the name of my spouse
(was) (is) ; his last known address is ; we were
married in the State of , County of on ; we
have been separated since ; we last had sexual relations on
.
( ) Divorced; the name of my former spouse is ; we were
married in the State of , County of on ;
his last known address is ; divorce granted in the State
of , County of .
( ) Legally Married; the name of my spouse (was) (is) ;
we were married in the State of , County of on
on ; and his last known address is .
( ) Married through common-law relationship prior to January 1,
1997; the name of my spouse (was) (is) ; his last known
address is ; our relationship began in the State of ,
County of on .
( ) Widowed; the name of my deceased spouse was ; we were
married in the State of , County of on ; and he
died on in the County of , State of .
That the name of the biological father of my child is (complete
appropriate response):
Known to me and is ( );
Known to me but I expressly decline to identify him because
; or
Unknown to me because
.
That the last known address of the biological father of my child
is (complete appropriate response):
Known to me and is ;
Known to me but I expressly decline to provide his address
because ; or
Unknown to me because
.
That, to the best of my knowledge, I (am) (am not) of American
Indian heritage. If so:
(A) The name of my American Indian tribe is and the
percentage of my American Indian blood is percent.
(B) My relatives with American Indian blood are:
(C) I (am) (am not) a member of an American Indian tribe. If
so, the name of the tribe is .
(D) I (am) (am not) registered with an American Indian tribal
registry. If so, the American Indian tribal registry is:
and my registration or identification number is:
.
(E) A member of my family (is) (is not) a member of an American
Indian tribe. If so, the name of each such family member is:
and the name of the corresponding American Indian tribe
is: .
(F) A member of my family (is) (is not) registered with an
American Indian tribal registry. If so, the name of each such
family member is: and the name of the corresponding
American Indian tribal registry is: and their
corresponding registration or identification numbers are: .
That to the best of my knowledge, the biological father (is) (is
not) of American Indian heritage. If so:
(A) The name of his American Indian tribe is and the
percentage of his American Indian blood is percent.
(B) His relatives with American Indian blood are:
.
(C) He (is) (is not) a member of an American Indian tribe. If
so, the name of the tribe is: .
(D) He (is) (is not) registered with an American Indian tribal
registry. If so, the American Indian tribal registry is:
and his registration or identification number is: .
That the date of birth of the biological father (was ,
) or (is not known to me).
That the biological father (is) (is not) on active duty in a
branch of the United States armed forces. If so:
(A) The branch of his service is (Army) (Navy) (Marine) (Air
Force) (Coast Guard).
(B) His rank is .
(C) His duty station is .
If applicable, please provide any additional available
information regarding his military service.
.
That the biological father of my child, whether or not identified
herein (strike each inappropriate phrase):
(Was) (Was not) married to me at the time this child was
conceived;
(Was) (Was not) married to me at any time during my pregnancy
with this child;
(Was) (Was not) married to me at the time that this child was
born;
(Did) (Did not) marry me after the child was born and recognize
the child as his own;
(Has) (Has not) been determined to be the child's father by a
final paternity order of a court;
(Has) (Has not) legitimated the child by a final court order;
(Has) (Has not) lived with the child;
(Has) (Has not) contributed to its support;
(Has) (Has not) provided for my support during my pregnancy or
hospitalization for the birth of the child;
(Has) (Has not) provided for my medical care during my
pregnancy or hospitalization for the birth of the child; and
(Has) (Has not) made any attempt to legitimate the child.
That I have received or been promised the following financial
assistance, either directly or indirectly, from whatever source, in
connection with my pregnancy, the birth of my child, and its
placement for adoption: .
That I recognize that if I knowingly and willfully make a false
statement in this affidavit, I will be guilty of the crime of false
swearing.
(Biological mother's signature)
Sworn to and subscribed
before me this
day of , .
Notary public (SEAL)
My Commission Expires .
(i) The affidavit of an adoptive mother required by subsection (a) of Code Section
19-8-9 for the surrender of her rights shall meet the following requirements:
(1) The affidavit shall set forth:
(A) Her name;
(B) Her relationship to the child;
(C) Her age;
(D) Her marital status;
(E) The name and last known address of any spouse at the time the child was adopted and whether any such spouse also adopted the child or was the biological father of the child;
(F) The circumstances surrounding her adoption of her child, including the date the adoption was finalized, the state and county where finalized, and the name and address of the adoption agency, if any; and
(G) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with the placement or arranging for the placement of her child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the adoptive mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the adoptive mother need only state the nature of the assistance received.
(2) The affidavit shall be in substantially the following form:
ADOPTIVE MOTHER'S AFFIDAVIT
NOTICE TO MOTHER:
This is an important legal document which deals with your child's
right to have its legal father's rights properly terminated. Understand
that you are providing this affidavit under oath and that the
information provided will be held in strict confidence and will be used
only in connection with the adoption of your child.
STATE OF GEORGIA
COUNTY OF
Personally appeared before me, the undersigned officer duly
authorized to administer oaths, , who, after having been sworn,
deposes and says as follows:
That my name is .
That I am the adoptive mother of a (male) (female) child born (
insert name of child ) in the State of , County of on (
insert birthdate of child ).
That I am years of age, having been born in the State of
, County of on .
That my marital status is (check the status and complete the
appropriate information):
( ) Single, never having been married.
( ) Separated but not legally divorced; the name of my spouse
is ; his last known address is ; we were married in
the State of , County of on ; we have been
separated since ; my spouse (did) (did not) also adopt said
child; my spouse (is) (is not) the biological father of said child.
( ) Divorced; the name of my previous spouse is ; we
were married in the State of , County of on ;
his last known address is ; divorce granted in the State
of , County of on ; my previous spouse (did)
(did not) also adopt said child; my previous spouse (is) (is not)
the biological father of said child.
( ) Legally married; the name of my spouse is ; we were
married in the State of , County of on ; his
last known address is ; my spouse (did) (did not) also
adopt said child; my spouse (is) (is not) the biological father of
said child.
( ) Married through common-law marriage relationship; the name
of my spouse is ; his address is ; the date and
place our relationship began is ( date, county, state ); my spouse
(did) (did not) also adopt said child; my spouse (is) (is not) the
biological father of said child.
( ) Widowed; the name of my deceased spouse is ; we
were married in the State of , County of on ;
he died on in the County of , State of ; he
(did) (did not) also adopt said child; and he (was) (was not) the
biological father of said child.
That I adopted my child in the State of , County of ;
That the final order of adoption was entered on ;
That there (was) (was not) an adoption agency involved in the
placement of my child with me for adoption; and if so its name was ,
and its address is .
That I have received or been promised the following financial
assistance, either directly or indirectly, from whatever source, in
connection with my child's placement for adoption: .
That I recognize that if I knowingly and willfully make a false
statement in this affidavit, I will be guilty of the crime of false
swearing.
(Adoptive mother)
Sworn to and subscribed
before me this
day of , .
Notary public
(j) The affidavit of an agency or department representative required by subsection (h) of Code Section
19-8-4 shall conform substantially to the following form:
AFFIDAVIT OF AGENCY OR
DEPARTMENT REPRESENTATIVE
Personally appeared before me, the undersigned officer duly authorized
to administer oaths, , who, after having been sworn, deposes and
says as follows:
That I am (position) of (department or agency).
That prior to the execution of the accompanying SURRENDER OF
RIGHTS/FINAL RELEASE FOR ADOPTION by , releasing and
surrendering all of (his) (her) rights in a (male) (female) minor child
born ( insert name of child ) on ( insert birthdate of child ), I
reviewed with and explained to said individual all of the provisions of
the surrender, and particularly the provisions which provide that the
surrender is a full surrender of all rights to the child.
That based on my review and explanation to said individual, it is my
opinion that said individual knowingly, intentionally, freely, and
voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.
(Agency representative)
Sworn to and subscribed
before me this
day of , .
Notary public
(k) The affidavit of a petitioner's representative required by subsection (h) of Code Section
19-8-5,
19-8-6, or
19-8-7 shall conform substantially to the following form:
AFFIDAVIT OF PETITIONER'S REPRESENTATIVE
Personally appeared before me, the undersigned officer duly authorized
to administer oaths, , who, after having been sworn, deposes and
says as follows:
That my name is .
That my address is .
That prior to the execution of the accompanying SURRENDER OF
RIGHTS/FINAL RELEASE FOR ADOPTION by , releasing and
surrendering all of (his) (her) rights in a (male) (female) minor child
born ( insert name of child ) on ( insert birthdate of child ), I
reviewed with and explained to said individual all of the provisions of
the surrender, and particularly the provisions which provide that the
surrender is a full surrender of all rights to the child.
That based on my review and explanation to said individual, it is my
opinion that said individual knowingly, intentionally, freely, and
voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.
(Petitioner's representative)
Sworn to and subscribed
before me this
day of , .
Notary public
(l) The parental consent to a stepparent adoption required by subsection (j) of Code Section
19-8-6 shall conform substantially to the following form:
PARENTAL CONSENT TO STEPPARENT ADOPTION
I, the undersigned, hereby consent that my spouse ( insert name of
spouse ) adopt my (son) (daughter), ( insert name of child ), whose date of
birth is , and in so doing I in no way relinquish or surrender my
parental rights to the child.
I further acknowledge service of a copy of the petition for adoption of
the child as filed on behalf of my spouse, and I hereby consent to the
granting of the prayers of the petition. I also waive all other and further
service and notice of any kind and nature in connection with the
proceedings.
This day of , .
(Parent)
Unofficial witness
Notary public
Graham Syfert - Jacksonville Lawyer 
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