Fillable SUPPORTING INFORMATION FOR ISSUANCE OF CALIFORNIA DEPARTMENT OF (California)

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SUPPORTING INFORMATION FOR ISSUANCE OF CALIFORNIA DEPARTMENT OF (California)

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The SUPPORTING INFORMATION FOR ISSUANCE OF CALIFORNIA DEPARTMENT OF (California) form is 2 pages long and contains:

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  • 10 check-boxes
  • 114 other fields

Country of origin: US
File type: PDF

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SUPPORTING INFORMATION FOR ISSUANCE OF
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ACKNOWLEDGEMENT AND CONFIRMATION OF
RECEIPT OF CHILD FREEING DOCUMENTS
Instructions: Prepare in duplicate; keep copy; send original to California Department of Social Services.
If additional space is necessary, use reverse side.
AGENCY
I. CHILD - NAME (Include all AKAs)
LAST: FIRST: MIDDLE:
BIRTHDATE: (MONTH/DAY/YEAR) GENDER: BIRTHPLACE: (CITY/STATE)
VERIFIED:
■ YES ■ NO
AKAs:
II. PARENT(S) - NAMES (Include all AKAs)
MOTHER
LAST: FIRST: MIDDLE:
BIRTHD
ATE: (MONTH/DAY/YEAR)
AKA:
AKA:
MOTHER DECEASED:
■
YES
■
NO VERIFIED:
■
YES
■
NO
■ ■ ■ ■
DATE OF DEATH: (MONTH/DAY/YEAR)
BIOLOGICAL FATHER
LAST: FIRST: MIDDLE:
BIR
THDATE: (MONTH/DAY/YEAR)
AKA:
AKA:
BIOLOGICAL FATHER DECEASED:
YES NO VERIFIED: YES NO
DATE OF DEATH: (MONTH/DAY/YEAR)
PRESUMED FATHER
LAST: FIRST: MIDDLE:
BIRTHDATE: (MONTH/DAY/YEAR)
AKA: AKA:
FATHER DECEASED:
■
YES
■
NO VERIFIED:
■
YES
■
NO
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DATE OF DEATH: (MONTH/DAY/YEAR)
ALLEGED NATURAL FATHER
LAST: FIRST: MIDDLE:
BIRTHDATE: (MONTH/DAY/YEAR)
AKA:
AKA:
ALLEGED NATURAL FATHER DECEASED:
YES NO VERIFIED: YES NO
DATE OF DEATH: (MONTH/DAY/YEAR)
III. MARITAL HISTORY OF MOTHER
■
MOTHER NEVER MARRIED:
Terminations - Month, Day, Year
Name of Spouse(s)
Continue on Reverse Side if Necessary
Marriage
Mo. Day Yr.
Verified
Yes No
Final
Annulment
Dissolution
Death-Husband Verified
Yes No
IV. CHECK IF APPLICABLE:
■ Mother is cohabiting with her husband who is not impotent or sterile and who is conclusively presumed to be this child’s father
pursuant to Family Code Section 7540. Therefore, no action was taken on any alleged natural father.
■ F
ather is rebuttably presumed to be this child’
s natural father because he meets the conditions of Family Code Section 7611(a),
(b), (c), (d) or (e).
■ Father is rebuttably presumed to be this child’s father because he meets the conditions of Family Code Sections 7573 and 7574
by the completion and filing of a voluntar
y declaration of paternity on or after January 1, 1997, and is identified on the child’s birth
certificate.
■
Father is conclusively presumed to be this child’s father because he meets the conditions of Family Code Section 7576 by the completion
of a voluntary declar
ation of paternity on or before December 31, 1996, and is identified on the child’s birth certificate.
■
Man is alleged to be this child’s natural father.
APPROVED BY:
SIGNATURE AND TITLE:
DATE:
Page 1 of 2
AD 90 (6/13)
NOTE: Paragraph VI on reverse side must be completed.
click to sign
signature
click to edit
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V. Check applicable box for parent relinquishing, waiving notice or denying paternity:
A. Parent competent to sign. Mother
Biological Father
relinquishing
waiving
Presumed Father
relinquishing
waiving
Alleged Natural Father
relinquishing
waiving
denying
B.
Parent is under psychiatric care.
(In-patient or out-patient)
Mother
Biological Father
relinquishing
waiving
Presumed Father
relinquishing
waiving
Alleged Natural Father
relinquishing
waiving
denying
Treating or supervising physician's
statement attached.
Show date of examination on
which statement is based.
Mother
Date
Biological Father
relinquishing
waiving
Date
Presumed Father
relinquishing
waiving
Date
Alleged Natural Father
relinquishing
waiving
denying
Date
C.
Parent is discharged from
hospital or psychiatric care.
Show date of verification of
discharge or termination.
■
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■ Mother
Date
.
Biological Father
■
relinquishing
■ waiving
Date
Presumed Father
■
relinquishing
■
waiving
Date
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Alleged Natural Father
■ relinquishing
■ waiving
■ denying
Date
VI. Does child have American Indian ancestry?
■
Yes
■
No If Yes, fill in A, B, C below, as applicable.
A. Bureau of Indian Affairs (BIA) or tribes determined
■
child is
■
is not subject to provisions of Indian Child Welfare Act (ICWA).
B. Reply to ICWA - 030, from BIA or tribes received on
Date
_____________________
(attach copy)
OR
C. Previous communication from BIA received
Date
_____________________
(attach copy)
AD 90 (6/13)
Page 2 of 2
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SUPPORTING INFORMATION FOR ISSUANCE OF CALIFORNIA DEPARTMENT OF (California)

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Completed 7 April 2022

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