Form AD929A "Waiver of Right to Revoke Relinquishment Agency Adoption Program" - California

Form form ad 929a or the "Form Ad929a "waiver Of Right To Revoke Relinquishment Agency Adoption Program" - California" is a form issued by the California Department of Social Services.

The form was last revised in December 1, 2016 and is available for digital filing. Download an up-to-date Form form ad 929a in PDF-format down below or look it up on the California Department of Social Services Forms website.

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Download Form AD929A "Waiver of Right to Revoke Relinquishment Agency Adoption Program" - California

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
CDSS
WAIVER OF RIGHT TO REVOKE RELINQUISHMENT
Copy:
Birth Parent
AGENCY ADOPTION PROGRAM
Copy:
Case Record
NOTE TO BIRTH PARENT: Do not sign this form unless you want to permanently relinquish your child for adoption. By
signing this form you are ending your right to revoke the relinquishment that you signed.
On_________________________, I signed a relinquishment for adoption (“the relinquishment”) in which I agreed to
DATE
relinquish my child,__________________________________________________________________________________,
CHILD’S NAME AS SHOWN ON RELINQUISHMENT
born on _______________________, to _________________________________________________________________.
DATE OF BIRTH
NAME OF ADOPTION AGENCY
In the Statement of Understanding, I understand I have options for when my relinquishment may be filed and acknowledged
by the California Department of Social Services (CDSS). If I choose to have this relinquishment filed immediately, I
understand it may take up to 10-business days for the CDSS to file and acknowledge my relinquishment. During this period,
prior to CDSS issuing an acknowledgement, I indicate that I understand I may revoke my relinquishment.
Birth parent must initial the following statements:
______
I understand that by signing this form I am waiving the holding period and therefore making the relinquishment for
INITIAL
adoption permanent and irrevocable effective immediately, or at the close of the next business day as noted in
“Birth parent must initial one of the following statements.”
______
I understand this waiver will become void if either of the following occurs: this relinquishment is determined to be
INITIAL
invalid or the relinquishment is revoked during any holding period indicated in the Statement of Understanding I
signed.
______
I understand that by signing this form I will not be able to gain custody of my child unless, after CDSS has
INITIAL
acknowledged my relinquishment, I request that it be rescinded and the adoption agency agrees that my
relinquishment may be rescinded.
Birth parent must initial one of the following statements:
______
If signing in front of a Judicial Officer, CDSS or delegated county representative within or outside of California, I
INITIAL
understand this waiver becomes effective immediately.
______
If signing this form in front of an authorized representative of a licensed private adoption agency within or outside
INITIAL
of California, I understand I have until___________________ on _________________, ___________________,
TIME
DAY OF WEEK
MONTH/DAY/YEAR
which is the end of the next business day following the signing of the waiver, to request the waiver be withdrawn.
If I decide to withdraw this waiver, I must contact the adoption agency by phone at
(
) ________________________ or in person at ________________________________________________.
ADDRESS
DATE SIGNED
SIGNATURE OF BIRTH PARENT
- PLEASE TURN PAGE OVER -
AD 929A (12/16) This form must be used with the following forms: AD 501, AD 501A, AD 504, AD 583, AD 584, AD 591, AD 593
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
CDSS
WAIVER OF RIGHT TO REVOKE RELINQUISHMENT
Copy:
Birth Parent
AGENCY ADOPTION PROGRAM
Copy:
Case Record
NOTE TO BIRTH PARENT: Do not sign this form unless you want to permanently relinquish your child for adoption. By
signing this form you are ending your right to revoke the relinquishment that you signed.
On_________________________, I signed a relinquishment for adoption (“the relinquishment”) in which I agreed to
DATE
relinquish my child,__________________________________________________________________________________,
CHILD’S NAME AS SHOWN ON RELINQUISHMENT
born on _______________________, to _________________________________________________________________.
DATE OF BIRTH
NAME OF ADOPTION AGENCY
In the Statement of Understanding, I understand I have options for when my relinquishment may be filed and acknowledged
by the California Department of Social Services (CDSS). If I choose to have this relinquishment filed immediately, I
understand it may take up to 10-business days for the CDSS to file and acknowledge my relinquishment. During this period,
prior to CDSS issuing an acknowledgement, I indicate that I understand I may revoke my relinquishment.
Birth parent must initial the following statements:
______
I understand that by signing this form I am waiving the holding period and therefore making the relinquishment for
INITIAL
adoption permanent and irrevocable effective immediately, or at the close of the next business day as noted in
“Birth parent must initial one of the following statements.”
______
I understand this waiver will become void if either of the following occurs: this relinquishment is determined to be
INITIAL
invalid or the relinquishment is revoked during any holding period indicated in the Statement of Understanding I
signed.
______
I understand that by signing this form I will not be able to gain custody of my child unless, after CDSS has
INITIAL
acknowledged my relinquishment, I request that it be rescinded and the adoption agency agrees that my
relinquishment may be rescinded.
Birth parent must initial one of the following statements:
______
If signing in front of a Judicial Officer, CDSS or delegated county representative within or outside of California, I
INITIAL
understand this waiver becomes effective immediately.
______
If signing this form in front of an authorized representative of a licensed private adoption agency within or outside
INITIAL
of California, I understand I have until___________________ on _________________, ___________________,
TIME
DAY OF WEEK
MONTH/DAY/YEAR
which is the end of the next business day following the signing of the waiver, to request the waiver be withdrawn.
If I decide to withdraw this waiver, I must contact the adoption agency by phone at
(
) ________________________ or in person at ________________________________________________.
ADDRESS
DATE SIGNED
SIGNATURE OF BIRTH PARENT
- PLEASE TURN PAGE OVER -
AD 929A (12/16) This form must be used with the following forms: AD 501, AD 501A, AD 504, AD 583, AD 584, AD 591, AD 593
WAIVER OF RIGHT TO REVOKE RELINQUISHMENT
AGENCY ADOPTION PROGRAM - CONTINUED
THIS SECTION TO BE COMPLETED BY WITNESS
I,______________________________________________________, have witnessed the signing of the Waiver of Right to
Revoke Relinquishment by_______________________________________on__________________________________,
DATE
BIRTH PARENT
in________________________________, ___________________________________________.
CITY
STATE
(See Family Code Section 8700.5)
Witness: I am
A representative of CDSS.
Date of interview with birth parent: ____________________________.
A representative of the____________________________________________________, a delegated
NAME OF AGENCY
county adoption agency in California. Date of interview with birth parent: __________________________.
A judicial officer of _______________________________ California court of record: legal counsel, if birth
parent is represented by independent legal counsel.
Date of interview with birth parent:_________________________ .
A judicial officer of the ___________________________________________, a court of record in the state of
__________________________________, the state where the Waiver of Right to Revoke Relinquishment is
being signed and where the birth parent is represented by independent legal counsel. Date of interview with
birth parent: ____________________________.
An authorized representative of a licensed adoption agency approved under the laws of the state of
_____________________________________________, the state where the waiver of rights is being
signed. (The waiver may be signed in the presence of an authorized representative only if the birth parent
or parents are represented by independent legal counsel.) I have informed the birth parent or birth parents of
the time period that he/she/they may request the waiver be withdrawn. That interview was conducted by
_________________________________, the independent legal counsel for the birth parent(s), on
______________________________. (A copy of the independent legal counsel s certification is attached.)
NOTE:
The waiver may be signed outside of California only if the birth parent resides outside of California or is located
outside of California for an extended period of time unrelated to the adoption.
NAME OF WITNESS
SIGNATURE OF WITNESS
ADDRESS:
TELEPHONE
(
)
To be completed by independent legal counsel for the birth parent(s) when signing in front of a licensed adoption
agency within or outside of California or judicial officer.
I am the independent legal counsel who represents the birth parent and I interviewed the birth parent.
On: __________,prior to the birth parent’s signature-on the waiver, I interviewed the birth parent, reviewed the waiver with
the birth parent, and counseIed the birth parent about the option to sign or refuse to sign the waiver, including the
consequences of each option. I have delivered to the birth parent and the adoption agency or adoption service provider,
the AD 929A and a certificate confirming to these facts.
NAME
SIGNATURE
PHONE NUMBER
ADDRESS
(
)
AD 929A (12/16)
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