Fill and Sign the Parental Rights Form

IN THE ___________COURT OF _______________ (County), _________________ (State) __________________ PETITIONER V. CAUSE NO. ____________ _________________ RESPONDENT Acknowledgment by Parent of Termination of Parental Rights I, ______________________ (Name of Parent), do hereby give notice and acknowledge that I have terminated any and all rights as a parent that I have to my ____________ (e.g., son/daughter) , named __________________ (Name of Child), age _______ (Age of Child) at the time of this notice and acknowledgment. On the ____ day of __________, 20____, the __________________ (Name of Court) for the County of _________________, State of ________________, entered an order stating that my parental rights were terminated due to ___________________________________________ _____________________________________________________________________________ (Description of Reason for Termination of Rights ). It is with great love and concern for my child that I have accepted this termination of my parental rights in the belief that my child can receive the care and attention ______ (he/she) deserves. WITNESS my signature this the _____ day of ___________, 20_____. ______________________________ Signature of Parent STATE OF _________________ COUNTY OF __________________ Personally appeared before me, the undersigned authority at law in and for the aforesaid jurisdiction, the within-named _____________________ (Name of Parent), who, after being by me first duly sworn, stated on oath that the matters and facts set forth in the above and foregoing Acknowledgement are true and correct as therein stated. ______________________________ Signature of Parent SWORN to and subscribed before me, this the _ day of _____________, 20_____. _________________________ Notary Public My Commission Expires:______________________