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).
This document was signed in the presence of the following:
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