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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTIFICATION OF PROCEDURE IN LIEU OF SIGNING RELINQUISHMENT, WAIVER OR DENIAL
(To be used for California Court Actions, Out-of-State Actions, and Foreign Born Children)
NAME OF CHILD BIRTHDATE
BIRTHPLACE
NAME OF MOTHER NAME OF BIOLOGICAL/PRESUMED FATHER(S)
NAME OF ALLEGED FATHER(S)
INSTRUCTIONS: PART I.
For items A through E, attach a copy of court order(s). For item F, attach (1) copy of notice to alleged natural father, (2) copy
of proof of service (affidavit or signed, certified mail receipt) and (3) agency statement regarding response from alleged natural
father and any action taken by him.
PART II.
Attach copies of relinquishment document(s) and/or court order(s).
I. COURT ACTION TAKEN IN CALIFORNIA ___________________________ COUNTY
DATE
COURT ACTION
NUMBER
A.
■ Child a foundling and referred to Agency (W&IC 366.26)
B.
■ Child an orphan and referred to Agency (FC 8705)
C.
■
Child declared free from parental custody and control and referred to agency
FC 7802
W&IC 366.26
■ Mother
■ Biological/Presumed Father(s)
■ Alleged Natural Father(s)
D. ■ Only Mother’s consent determined necessary (FC 7630)
E.
■ Alleged Natural Father’s rights terminated by court action (FC 7660)
F. ■ Alleged Natural Father failed to bring action pursuant to FC 7630 in response to notice of adoption
planning (FC 7666)
Date 30 Days Expired
II. ACTION TAKEN IN ANOTHER STATE
Note:
Please attach a statement from the out-of-state adoption agency that the relinquishment taken meets the laws of that state and
transfers total legal care, custody and control of the child from the birth parent to the agency.
A. CHILD RELINQUISHED TO AUTHORIZED AGENCY IN ANOTHER STATE IN ACCORDANCE WITH THE LAW OF THAT JURISDICTION.
■
Biological/Presumed Father(s)
Mother
Date
NAME OF OUT-OF-STATE AGENCY REPORTING ACTION
■
Alleged Natural Father(s)
Date
B. PARENTAL RIGHTS TERMINATED BY COURT ACTION IN ANOTHER STATE IN ACCORDANCE WITH THE LAW OF THAT JURISDICTION.
■ Mother
DATE ACTION NUMBER
■ Biological/Presumed Father(s)
■ Alleged Natural Father(s)
COUNTY STATE NAME OF OUT-OF-STATE AGENCY REPORTING ACTION
C. CHILD RELINQUISHED IN A COURT PROCEEDING IN ANOTHER STATE ACCORDING TO THE LAW OF THAT JURISDICTION.
■ Mother
DATE
ACTION/FILE NUMBER
■ Biological/Presumed Father(s)
■ Alleged Natural Father(s)
COUNTY STATE NAME OF OUT-OF-STATE AGENCY (IF APPLICABLE)
III. ACTION TAKEN IN ANOTHER COUNTRY FOR FOREIGN BORN CHILDREN
CHILD’S NATIVE COUNTRY DATE OF RELEASE
NAME OF PERSON WHO IRREVOCABLY RELEASED CHILD FOR EMIGRATION AND SUBSEQUENT
ADOPTION IN U.S.
RELATIONSHIP TO CHILD (NATURAL PARENT/LEGAL GUARDIAN OR COURT ACTION)
LIAISON AGENCY TO WHOM CHILD WAS RELEASED FOR EMIGRATION AND ADOPTION COURT ACTION NUMBER AND PLACE OF ACTION (IF APPLICABLE)
RELEASE DOCUMENTS SPECIFY:
■
1) Child may be adopted by family selected U.S. Adoption Agency
■ 2) Child may be adopted only by persons named on release documents
SIGNATURE OF AGENCY REPRESENTATIVE NAME OF AGENCY DATE
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