Form Ad928 "Revocation of Consent - Independent Adoption Program" - California

Form AD928 or the "Revocation Of Consent - Independent Adoption Program" is a form issued by the California Department of Social Services.

Download a fillable PDF version of the Form AD928 down below or find it on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
Court Record
REVOCATION OF CONSENT
Copy:
Birth Parent
INDEPENDENT ADOPTION PROGRAM
Copy:
Case Record
INSTRUCTIONS:
This form is to be signed by the birth parent who wishes to revoke his or her consent, including an Independent Adoption
Placement Agreement, to the independent adoption of his or her child. The completed and signed revocation form is valid
only if it is delivered to the California Department of Social Services (CDSS) or the delegated county adoption agency,
whichever is investigating the proposed independent adoption, before the 30-day period has ended. The first day of the
30-day period is the day the consent is signed. It is not valid if the parent has signed a Waiver of Right to Revoke Consent-
Independent Adoption Program form (AD 929). The agency representative who receives the form shall complete Section B
and give a copy of the form to the parent who signed the form.
Section A:
I,_______________________________________________, the mother/father of__________________________________
BIRTH PARENT’S NAME
NAME OF CHILD
born on_________________________________, revoke my consent to adoption by, or the Independent Adoption Placement
DATE OF BIRTH
Agreement entered into with,____________________________________________________________________signed
NAMES OF PETITIONERS/PROSPECTIVE ADOPTIVE PARENTS
on_______________________.
DATE
I request that the child be returned to me his or her birth parent.
DATE SIGNED
SIGNATURE OF PARENT
Section B:
To be completed by the representative of the California Department of Social Services or Delegated County Adoption Agency
receiving the form:
DATE RECEIVED:
PERSON RECEIVING FORM:
AGENCY NAME:
ADDRESS:
AD 928 (7/02)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
Court Record
REVOCATION OF CONSENT
Copy:
Birth Parent
INDEPENDENT ADOPTION PROGRAM
Copy:
Case Record
INSTRUCTIONS:
This form is to be signed by the birth parent who wishes to revoke his or her consent, including an Independent Adoption
Placement Agreement, to the independent adoption of his or her child. The completed and signed revocation form is valid
only if it is delivered to the California Department of Social Services (CDSS) or the delegated county adoption agency,
whichever is investigating the proposed independent adoption, before the 30-day period has ended. The first day of the
30-day period is the day the consent is signed. It is not valid if the parent has signed a Waiver of Right to Revoke Consent-
Independent Adoption Program form (AD 929). The agency representative who receives the form shall complete Section B
and give a copy of the form to the parent who signed the form.
Section A:
I,_______________________________________________, the mother/father of__________________________________
BIRTH PARENT’S NAME
NAME OF CHILD
born on_________________________________, revoke my consent to adoption by, or the Independent Adoption Placement
DATE OF BIRTH
Agreement entered into with,____________________________________________________________________signed
NAMES OF PETITIONERS/PROSPECTIVE ADOPTIVE PARENTS
on_______________________.
DATE
I request that the child be returned to me his or her birth parent.
DATE SIGNED
SIGNATURE OF PARENT
Section B:
To be completed by the representative of the California Department of Social Services or Delegated County Adoption Agency
receiving the form:
DATE RECEIVED:
PERSON RECEIVING FORM:
AGENCY NAME:
ADDRESS:
AD 928 (7/02)
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