Fill and Sign the Department of Health Ampamp Human Services or Agency Surrender Form

NHJB-2081-FP (10/01/2006) Page 1 of 1 (formerly AOC-082S A-003) THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H Cour t Na m e: Ca se Nam e: Ca se Num ber: (if k now n) DEP AR TM ENT OF HE ALTH AN D HU M AN SERVI CES OR AG ENCY SURRENDER OF P AREN TAL RI GHTS (RSA 170- B: 5 through 170- B: 12) 1. Nam e of agency su rrend ering r ights Ex ecut ive head or aut ho rized r epr esent ative Telephone Em ail addr ess Mailing Addr es s 2. Nam e of Child Date of b irth Place o f bir th 3. Nam e of bir th mother Dat e of bir th mother’s su rrender or terminat ion o f par ent al rights (TPR) Place o f su rrende r or TPR Case num be r 4. Nam e of bir th father Dat e of bir th father’s su rrender or terminat ion o f parent al rights (TPR) Place o f su rrende r or TPR Case num be r Pl ease r ead c areful ly the i nfor mati on bel ow befor e si gning thi s docu m en t. By com plet ing t his sur render of pa rent al right s, I under stand tha t my depa rtment or agency w ill cont inue t o hav e a leg al relat ionship wit h the child, giving the depar tm ent or a gency responsibilit y for ov ersig ht of the suppor t, medical, an d o ther ca re of the minor child unt il a final decr ee o f adopt ion has been issued . I under stand that tempor ary car e, cus tody and con trol o f the child w ill be t ransferred to the adop tive par ent s dur ing t his int erlocu tory per iod. By sig ning t his do cum ent below , I declar e: h that I repr esen t the d epar tm ent or agency hav ing ca re, cus tody and co ntrol o f the child; h that all t he in formation on this su rrende r form is true; h that I hav e r ead and under stand the con tent o f this docu ment; and h that I w ish th is su rre nder o f p arental righ ts to take effe ct. Date Sig nat ure of Ex ec utive Hea d or Auth orized Repr es enta tive St ate of , Count y of This ins trument w as ac knowledg ed be fore m e on by My Com mission Ex pir es Affix Seal , if any Sig nat ure of Not arial O fficer / T itle ORDE R This sur render of par en tal r ights is: Appr ov ed Not appr ov ed Date Judge