Withdrawal of Parental Consent to Adoption

WITHDRAWAL OF PARENTAL CONSENT TO ADOPTION

 

On ___________ (Date), I, _____________________________, the ______________ (Father/Mother) of ____________________________, a ___________ (Male/Female) child born on _____________ (Date), consented to ________ (His/Her) adoption by ____________________________________ and _____________________________(Adoptive Parents).

I declare my intention to revoke my consent to said adoption agreement on the grounds that the following changes in my circumstances establish it to be in the best interest of ___________________________ (Child) to remain in my care and custody: _____________________________________________________ _____________________________________________________.

Therefore, I do hereby revoke my consent to the adoption agreement and declare said adoption agreement to be void and of no further effect.

In witness whereof, I have signed this instrument at ____________________________ (Place of Execution).

_________________________________ __________________

Signature Date

This document was signed in the presence of the following:

_________________________________ __________________

Signature Date

_________________________________ __________________

Signature Date

 

 

Warning:

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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