I, as the of , age , of
the sex, born in , on ,
do hereby voluntarily and unconditionally surrender to the
care and custody of for the purpose of adoption or
such other disposition as may be made by a court of competent jurisdiction. I waive notice of any
legal proceeding affecting the custody, guardianship, adoption or other disposition of
.
I UNDERSTAND THAT THIS SURRENDER IS FINAL AND CANNOT BE REVOKED.
Signature:
On this day of , , before me personally came and
appeared and in my presence duly executed the foregoing
instrument, and (he, she) acknowledged to me that (he, she) executed the same as (his, her) free
act and deed, fully cognizant of its irrevocability.
Date
State of
Notary Public
County of
Signed by as (his, her) freely executed consent in the
presence of each of us, and of each other, who thereafter have hereunto signed our names as
witnesses.
1) 2)
WRITTEN CONSENT PURSUANT TO M. G. L. c. 210, § 2
[VOLUNTARY AND UNCONDITIONAL SURRENDER]
(type or print - complete in triplicate)
(relationship to child: mother/father) (name of child)
(male/female) (place of birth) (date of birth)
(name of child)
(name of child)
(agency or person receiving custody)
(person giving consent)
(day) (month) (year)
(Witness No. 1 Signature)
(person giving consent)
(Witness No. 2 Signature)
(Address) (Address)
