Form AD 1A Parental Consent to Adoption (In or out-Of-California) - California

Form AD1A is a California Department of Social Services form also known as the "Parental Consent To Adoption (in Or Out-of-california)". The latest edition of the form was released in April 1, 2015 and is available for digital filing.

Download an up-to-date fillable Form AD1A in PDF-format down below or look it up 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
PARENTAL CONSENT TO ADOPTION
Copy:
Parent
(In or Out-of-California)
Copy:
Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
PETITIONER(S)
I, ________________________________________________________________________________ being the (Choose One):
NAME OF PARENT
I
Birth Mother
I
Presumed Father
I
Biological Father
I
Other Legal Parent _________________________________
of ___________________________________________________ (Gender:
I
M
I
F) born on ________________________
NAME OF CHILD
in ___________________________________________________ give my full and free consent to the adoption of said child by
PLACE OF BIRTH
____________________________________________________________________________________,
NAME(S) OF PETITIONER(S)
I understand that I may revoke this consent ONLY DURING THE THIRTY (30) DAY PERIOD beginning on the date I sign this
consent and ONLY IF I HAVE NOT WAIVED MY RIGHT TO REVOKE THE CONSENT. I further understand that with the signing
of the order of adoption by the court I shall give up all rights of custody, services, and earnings of said child and I may not reclaim
said child.
SIGNATURE OF PARENT
DATE
FULL ADDRESS
SECTION A
Complete If Signed In California
I, ________________________________________________, a representative of ___________________________________
NAME OF CDSS OR DELEGATED COUNTY ADOPTION AGENCY
NAME OF AGENCY REPRESENTATIVE
have witnessed the signing of this consent to adoption by the above named parent on ______________________________ in
DATE
_________________________________________________.
COUNTY WHERE SIGNED
SIGNATURE OF AGENCY REPRESENTATIVE
TITLE OF AGENCY REPRESENTATIVE
FULL ADDRESS
TELEPHONE NUMBER
SECTION B
Complete If Signed Outside Of California*
***THIS FORM MUST BE SIGNED BY A NOTARY PUBLIC WHEN SIGNED OUTSIDE OF CALIFORNIA***
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
*If signing outside the United States this section must meet the requirements of California Civil Code Section 1183
AD 1A (Combined with AD 1C (4/15)
STATE OF CALIFORNIA — HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original: Court Record
PARENTAL CONSENT TO ADOPTION
Copy:
Parent
(In or Out-of-California)
Copy:
Case Record
COUNTY
In the Matter of the Petition of
ACTION NUMBER
PETITIONER(S)
I, ________________________________________________________________________________ being the (Choose One):
NAME OF PARENT
I
Birth Mother
I
Presumed Father
I
Biological Father
I
Other Legal Parent _________________________________
of ___________________________________________________ (Gender:
I
M
I
F) born on ________________________
NAME OF CHILD
in ___________________________________________________ give my full and free consent to the adoption of said child by
PLACE OF BIRTH
____________________________________________________________________________________,
NAME(S) OF PETITIONER(S)
I understand that I may revoke this consent ONLY DURING THE THIRTY (30) DAY PERIOD beginning on the date I sign this
consent and ONLY IF I HAVE NOT WAIVED MY RIGHT TO REVOKE THE CONSENT. I further understand that with the signing
of the order of adoption by the court I shall give up all rights of custody, services, and earnings of said child and I may not reclaim
said child.
SIGNATURE OF PARENT
DATE
FULL ADDRESS
SECTION A
Complete If Signed In California
I, ________________________________________________, a representative of ___________________________________
NAME OF CDSS OR DELEGATED COUNTY ADOPTION AGENCY
NAME OF AGENCY REPRESENTATIVE
have witnessed the signing of this consent to adoption by the above named parent on ______________________________ in
DATE
_________________________________________________.
COUNTY WHERE SIGNED
SIGNATURE OF AGENCY REPRESENTATIVE
TITLE OF AGENCY REPRESENTATIVE
FULL ADDRESS
TELEPHONE NUMBER
SECTION B
Complete If Signed Outside Of California*
***THIS FORM MUST BE SIGNED BY A NOTARY PUBLIC WHEN SIGNED OUTSIDE OF CALIFORNIA***
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
*If signing outside the United States this section must meet the requirements of California Civil Code Section 1183
AD 1A (Combined with AD 1C (4/15)

Download Form AD 1A Parental Consent to Adoption (In or out-Of-California) - California

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