Fill and Sign the Before Me the Undersigned Notary Public and in the Presence of the Two Undersigned Form

VOLUNTARY ACT OF SURRENDER FOR ADOPTION STATE OF ___________ COUNTY OF ___________ BEFORE ME, the undersigned Notary Public, and in the presence of the two undersigned competent witnesses who are over the age of eighteen, personally came and appeared ___________, a male of the age of ___________ (______), who is single and domiciled in the County of ___________, State of ___________, who, being first duly sworn, did depose and state: (l) He is the natural father of ___________, born on ______ ___, 20___, in the Parish of ___________, State of Louisiana. (2) He was not married to and has not married the mother of this child. He has not executed a notarial act of acknowledgment or a notarial act of legitimation or a registration with the putative father regi stry which admitted his paternity of this child. He has informally acknowledged his paternity of this child. His paternity of this child has not been established by court judgment. (3) The natural mother of the child is ___________, and her current address is ___________. (4) The person to whom this child is hereby surrendered is ___________, whose current address is ___________. (5) The court in which this surrender is to be filed is the ______ Judicial District Court, ___________, ___________ Parish. (6) Affiant declares that this Act of Surrender is not being executed earlier than the fifth day following the birth of the child. (7) Affiant declares that he has no mental incapacity and is under no interdiction. (8) Affiant declares that he has been informed and understands that his rights as a natural parent of the child are permanently and irrevoca bly terminated by execution of this Act of Surrender. (9) Affiant declares that he freely and voluntarily surrenders custody of this child for the purpose of placement and adoption. (l0) Affiant declares that he consents to an adoption, which consent is final and irrevocable upon the execution of this surrender. (11) Affiant declares that he waives notice of the filing and servic e of any pleading of any sort in any subsequent adoption proceeding regard ing the child surrendered. (12) Affiant declares that he has been informed of the provisions of the voluntary registration law, whereby contact may be established with the surrendered child upon the child's reaching the age of eighteen years. (13) Affiant declares that he waives mental health counseling relative to the surrender of this child for adoption. (14) Affiant declares that he is eighteen years of age or older. (15) Affiant declares that he has consulted with and been fully advised by an attorney other than the attorney for ___________ about the meaning of these declarations and the consequences of this Act of Surrender. SWORN TO, SIGNED AND NOTARIZED after being carefully read and e xplained to ___________ in the presence of the undersigned Notary and witnesses on this _______ day of __________, 20___. WITNESSES: ___________________________ _______________________________ ___________ SURRENDERING FATHER ___________________________ ________________________________ ___________ ATTORNEY FOR SURRENDERING FATHER _______________________________ NOTARY PUBLIC AND SEAL MY COMMISSION EXPIRES: ______________ THUS DONE AND SIGNED by ___________ in the presence of the undersigned competent witnesses and me, Notary Public in and for the Parish of ___________, Louisiana, on thi s ______ day of ____________, 20___. WITNESSES: _____________________________ _________________________________ ___________ MOTHER OF CHILD _____________________________ __________________________________ NOTARY PUBLIC AND SEAL MY COMMISSION EXPIRES: ______________ ATTACHMENTS: STATEMENT OF FAMILY HISTORY STATEMENT OF FAMILY HISTORY (1) State ages of biological parents: FATHER ________ (2) Race of biological parents: FATHER _________ (3) State whether either of the biological parents or any of their immediate families ha ve ever had the following: YES NO ( ) ( ) Cancer ( ) ( ) Heart trouble ( ) ( ) Diabetes ( ) ( ) Epilepsy ( ) ( ) Stroke ( ) ( ) Asthma ( ) ( ) Arthritis ( ) ( ) Kidney Ailments ( ) ( ) Tuberculosis ( ) ( ) Alcoholism ( ) ( ) Blindness ( ) ( ) Deafness ( ) ( ) Neurological and Muscular ______________ ________________________________________ (Specify) ( ) ( ) Drug Abuse _____________________________ ________________________________________ (Specify) ( ) ( ) Mental Illness _________________________ ________________________________________ (Specify) ( ) ( ) Allergies ______________________________ ________________________________________ (Specify) ( ) ( ) Blood Disease __________________________ ________________________________________ (Specify) ( ) ( ) Venereal Disease _______________________ ________________________________________ (Specify) ( ) ( ) Mental Retardation _____________________ ________________________________________ (Specify) ( ) ( ) Glandular Disturbance __________________ ________________________________________ (Specify) ( ) ( ) High Blood Pressure (4) Please state whether the minor child has had the following shots: YES NO ( ) ( ) 2 mos. DPT + OPV ( ) ( ) 4 mos. DPT + OPV ( ) ( ) 6 mos. DPT ( ) ( ) 9 mos. MGB ( ) ( ) 12 mos. TB ( ) ( ) 15 mos. MMR ( ) ( ) 18 mos. DPT + OPV Booster ( ) ( ) 24 mos. TB ( ) ( ) 36 mos. TB ( ) ( ) 48 mos. TB ( ) ( ) 5 yrs. DPT + OPV Booster ( ) ( ) 5 yrs. TB (5) Please state whether the minor child has had the following illness: YES NO ( ) ( ) Pertussis ( ) ( ) Rubella ( ) ( ) Mumps ( ) ( ) Chicken Pox ( ) ( ) Scarlet Fever ( ) ( ) Diphtheria ( ) ( ) Appendicitis ( ) ( ) Rheumatic Fever ( ) ( ) Tonsillitis ( ) ( ) Convulsions ( ) ( ) Asthma ( ) ( ) Allergies ______________________________ ________________________________________ (Specify) ( ) ( ) Glandular Disturbance __________________ ________________________________________ (Specify) ( ) ( ) Operations _____________________________ ________________________________________ ________________________________________ (Specify)