Certificate of Relinquishment of Child Custody



This certifies that the attached document, executed on ____________(Date), by _____________________________ (Name) of _____________________________ __________________________________ (Address), relinquishing custody of the child named _________________________ (Name), to _____________________________, an agency authorized to place children for adoption in a suitable home, was executed in accordance with the laws of ___________________________ (State); and that the above-named child was placed for adoption with _____________________________ and ______________________________ (Names), of _____________________________________________________(Address), who ____________ (Has/Have) filed a petition to formally adopt the above-named child in the Court of _____________________________________________ (Name and Address of Court).

Approval is granted for completion of the above-referenced adoption.

In witness whereof, I have signed this instrument in my capacity as the duly authorized representative of ________________________________________ (Agency).

_______________________ _____________

Signature and Title




These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.

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