Form AD 20 Refusal to Give Parental Consent to Adoption - California

Form AD20 or the "Refusal To Give Parental Consent To Adoption" is a form issued by the California Department of Social Services.

The form was last revised in April 1, 2015 and is available for digital filing. Download an up-to-date fillable Form AD20 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
REFUSAL TO GIVE PARENTAL CONSENT TO ADOPTION
Copy:
Parent
(Birth Mother/Presumed/Biological Father/Legal Parent)
Copy:
Case Record
INSTRUCTIONS:
COUNTY:
1.
This form is to be completed by the legal parent who refuses to consent to the
adoption of his/her child.
ACTION NUMBER:
2.
The legal parent must initial each statement and sign at the bottom of the form.
3.
Complete Section A or B as explained below.
I, ______________________________________________________________________________ being the (Choose One):
NAME OF LEGAL PARENT
Birth Mother
Presumed Father
Biological Father
Other Legal Parent __________________________________
I
I
I
I
of ________________________________________________________ (Gender:
M
F) born on __________________
I
I
NAME OF CHILD
DATE OF BIRTH
refuse to give my consent to adoption of said child by _________________________________________________________
.
NAME OF PETITIONER(S)
I understand I have the right to retain a lawyer to assist me with this matter.
________
INITIAL
I understand that by signing this form it does not stop the adoption. I understand that if I want to stop the adoption I
________
must take legal action as soon as possible.
INITIAL
I understand that the petitioner(s) can go to court and ask the court to end my rights as this child’s parent.
________
INITIAL
SIGNATURE OF LEGAL PARENT
DATE
SECTION A
Complete if signed in California
SIGNATURE OF AGENCY REPRESENTATIVE (CDSS or Delegated County Adoption Agency)
DATE
NAME OF AGENCY REPRESENTATIVE
TELEPHONE NUMBER
NAME OF AGENCY (CDSS or Delegated County Adoption Agency)
COUNTY WHERE SIGNED
FULL ADDRESS
SECTION B
Complete if signed Outside-of-California*
***THIS FORM MUST BE WITNESSED 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 with the requirements of California Civil Code Section 1183.
AD 20 (ENG/SP) (4/15)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Original:
Court Record
REFUSAL TO GIVE PARENTAL CONSENT TO ADOPTION
Copy:
Parent
(Birth Mother/Presumed/Biological Father/Legal Parent)
Copy:
Case Record
INSTRUCTIONS:
COUNTY:
1.
This form is to be completed by the legal parent who refuses to consent to the
adoption of his/her child.
ACTION NUMBER:
2.
The legal parent must initial each statement and sign at the bottom of the form.
3.
Complete Section A or B as explained below.
I, ______________________________________________________________________________ being the (Choose One):
NAME OF LEGAL PARENT
Birth Mother
Presumed Father
Biological Father
Other Legal Parent __________________________________
I
I
I
I
of ________________________________________________________ (Gender:
M
F) born on __________________
I
I
NAME OF CHILD
DATE OF BIRTH
refuse to give my consent to adoption of said child by _________________________________________________________
.
NAME OF PETITIONER(S)
I understand I have the right to retain a lawyer to assist me with this matter.
________
INITIAL
I understand that by signing this form it does not stop the adoption. I understand that if I want to stop the adoption I
________
must take legal action as soon as possible.
INITIAL
I understand that the petitioner(s) can go to court and ask the court to end my rights as this child’s parent.
________
INITIAL
SIGNATURE OF LEGAL PARENT
DATE
SECTION A
Complete if signed in California
SIGNATURE OF AGENCY REPRESENTATIVE (CDSS or Delegated County Adoption Agency)
DATE
NAME OF AGENCY REPRESENTATIVE
TELEPHONE NUMBER
NAME OF AGENCY (CDSS or Delegated County Adoption Agency)
COUNTY WHERE SIGNED
FULL ADDRESS
SECTION B
Complete if signed Outside-of-California*
***THIS FORM MUST BE WITNESSED 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 with the requirements of California Civil Code Section 1183.
AD 20 (ENG/SP) (4/15)
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