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

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:
   1. Her name;
   2. Her relationship to the child;
   3. Her age;
   4. Her marital status;
   5. The identity and last known address of any spouse or former spouse;
   6. 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;
   7. 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
   8. 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
      1. 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:
   9. Her name;
   10. Her relationship to the child;
   11. Her age;
   12. Her marital status;
   13. 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;
   14. 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
   15. 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 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 ______________.

The affidavit shall set forth:

(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

(Code 1981, §19-8-26, enacted by Ga. L. 1990, p. 1572, § 5; Ga. L. 1999, p. 81, § 19; Ga. L. 1999, p. 252, § 10; Ga. L. 2000, p. 136, § 19; Ga. L. 2000, p. 1589, § 4; Ga. L. 2004, p. 631, § 19; Ga. L. 2007, p. 342, § 9/HB 497; Ga. L. 2008, p. 324, § 19/SB 455; Ga. L. 2009, p. 8, § 19/SB 46; Ga. L. 2009, p. 453, § 2-2/HB 228; Ga. L. 2009, p. 800, § 4/HB 388; Ga. L. 2011, p. 573, § 7/SB 172.)

Delayed effective date.

- For information as to the delayed amendment of this article, see the delayed effective date note at the beginning of this article.

Cross references.

- Juvenile court orders terminating parental rights, § 15-11-81 et seq.

Editor's notes.

- Ga. L. 2009, p. 800, § 1HB/388, not codified by the General Assembly, provides that: "This Act shall be known and may be cited as the 'Option of Adoption Act.'"