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ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF IMPERIAL 939 W. MAIN STREET EL CENTRO, CA 92243

PETITIONER:

RESPONDENT:

CONSENT BY BIRTH PARENT CASE NUMBER:
Consent to Adoption by Birth Parent
Family Code 9003

I, ______________________, being the parent of , do hereby (Print Name) (Name of Child) give my full and free consent to the adoption of said child by. (Name of Petitioner (Stepparent)) I fully understand that with the signing of this document my consent may not be withdrawn except with

court approval, and that with the signing of the order of adoption by the court, I lose all my rights of

custody, services, and earnings of said child, and that said child cannot be reclaimed by me.

Said child was born on _________________ in ________________________________ and is the child (Date) (City and State) of _________________________________ and _________________________________. (Name of Birth Parent) (Name of Birth Parent)

Executed at _____________________________ on Date ______________________ 20______ . (County and State/Country)

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Signature of Parent Form of picture ID SIGNED IN THE PRESENCE OF:

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Name

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Signature Title* *The consent of either or both birth parents shall be signed in the presence of a notary public, court clerk, probation officer, qualified court investigator, authorized representative of a licensed adoption agency, or county welfare department staff member of any county of this state. NOTICE TO THE BIRTH PARENT WHO CONSENTS TO THE CHILD’S ADOPTION: If you or your child lived together at any time as parent and child, the adoption of your child by a stepparent does not affect the child’s right to inherit your property or the property of blood relatives. For further information regarding this right of inheritance, you should consult an attorney. AD-02 (Adopted 01/01/12, Revised 01/01/13, 01/01/14) CONSENT BY BIRTH PARENT www.imperial.courts.ca.gov