Fill and Sign the Relinquish 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 __________________ (N ame 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: ______________________