____________________________________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
REQUEST FOR RESCISSION OF RELINQUISHMENT
(for agency use when relinquishment has been filed with and acknowledged by CDSS)
TO AGENCY:
AGENCY NAME
ADDRESS
TELEPHONE NUMBER
( )
TO PARENT:
Your request to rescind your relinquishment must be confirmed in writing. Complete and sign the below portion of this form and
return the entire form to the above agency address within 14 days after you receive it, or by
___________________________.
If this form is not returned by this date, your request for rescission is cancelled.
I,
__________________________________________________________
mother/father of
(NAME OF PARENT)
____________________________________________________________ ,
a minor, relinquished to
(NAME OF CHILD)
(NAME OF AGENCY)
now desire to rescind the relinquishment, signed on
____________________________
and to restore my
(DATE)
parental rights. I understand that this will not happen unless the agency agrees and completes the bottom
portion of this form.
(SIGNATURE OF PARENT)
(DATE)
To be completed by Agency Representative:
The
_________________________________________________________
agrees with the above-named
(NAME OF AGENCY)
parent to rescind the said relinquishment and to declare it to be of no force and effect.
(NAME OF AGENCY REPRESENTATIVE)
(TITLE)
(SIGNATURE OF AGENCY REPRESENTATIVE)
(DATE)
(Agency:
Return one copy to the California Department of Social Services)
AD 508 (7/13)
