Fill and Sign the Department of Hhs or Agency Surrender of Parental Rights Form

NHJB-2080-FP (10/01/2009) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Surrender of Parental Rights over SURRENDER OF PA RENTAL RIGHTS Of: Birth Mother Birth Father Legal Father (RSA 170-B:5 through 170-B:12) 1. Name of parent surrendering rights Telephone City/town, state of residence Mailing Address Date of Birth Place of Birth 2. Attorney for surrendering parent Telephone Mailing Address 3. Name of other parent Telephone City/town, state of residence Mailing Address Date of Birth Place of Birth 4. Child Name Date of Birth Place of Birth 5. Is the child an Indian child as defined by the Indian Child Welfare Act? Yes No If yes, name and address of tribe Is tribe recognized by the federal government as e ligible for federal services or certain Alaskan native corporations as def ined in 43 U.S.C. §1602(c)? Yes No 6. Birth mother’s marital status: Single Married Divorced Widowed If married, divorced or widowed, nam e of spouse If applicable, date of marriage date of divorce 7. Do you know the identity of the adoptive parents? Yes No 8. Are there any pending adoption, termination of parental rights, juvenile, domestic violence, marriage dissolution, domestic relations, paternity , legitimation, custody or other proceedings affecting minor or paren ts of this minor? Yes No If yes, attach a separate sheet identifying and explaining each. Case Name: Surrender of Parental Rights over Case Number: SURRENDER OF PARENTAL RIGHTS NHJB-2080-FP (10/01/2009) Page 2 of 3 Please read carefully or complete the in formation below before signing this document. By completing this surrender of parental rights, I understand that my parental rights over the child, including the rights of care, cust ody and control of the child, will ce ase when the court approves this surrender. I also waive any right to receive any notices about future hearings about the child. I understand that after the court approves this surrender, all my parental obligations will be extinguished, except the obligation to pay any accrued unpaid child support. I understand that after the court approves this su rrender in compliance with New Hampshire law, the surrender is final, and may not be revoked or set asi de for any reason, unless the court finds that the surrender was obtained by fr aud or duress, and that the withdrawal of the surrender is in the best interests of the adoptee. The failure of an adoptive parent to comply with an arrangement or understanding reached with t he birth parent with respect to the pos t-surrender exchange of identifying or non-identifying information, comm unication or contact is not a reason to revoke or set aside a surrender. I have been informed that child placing agencies dul y licensed pursuant to RSA 170-E are available to counsel me about my decision to surrender my parental rights. I have been provided legal counsel, unless waived with approval of the court. I have not received or been promised any money or anything of value for the completion of this surrender, except for payments pe rmissible under New Hampshire law. They are as follows: By signing this document below, I declare:  that I am the parent of the above named child;  that all the information on this surrender form is true;  that I have read and understand t he content of this document;  that all of my questions have been answered by the court or its designee;  that I wish this surrender of parental rights to take effect; and  that (please check one of the following): I do not wish to receive confirmation of the final adoption of this child. I wish to receive confirmation of the final adoption of this child. Date Signature State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Judge / Notarial Officer / Title Case Name: Surrender of Parental Rights over Case Number: SURRENDER OF PARENTAL RIGHTS NHJB-2080-FP (10/01/2009) Page 3 of 3 If the surrendering parent is a minor or under guardianship, complete the following section. We, , are the parents or guardians of the named birth parent who is surrendering his/her rights, and hereby give our assent to this surrender. Signature / Relationship Address Signature / Relationship Address State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER This surrender of parental rights is: Approved Not approved Date Judge