(a) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-4 shall conform substantially to the following form:

SURRENDER OF RIGHTS FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are surrendering all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You are to receive a copy of this document and as explained below have the right to withdraw your surrender within ten days from the date you sign it.

_______________

I, the undersigned, being solicitous that my (male) (female) child, born (insert_name_of_child) on (insert_birthdate_of_child), should receive the benefits and advantages of a good home, to the end that (she) (he) may be fitted for the requirements of life, consent to this surrender.

I, the undersigned, (insert_relationship_to_child) of the aforesaid child, do hereby surrender the child to (insert_name_of child-placing_agency_or_Department_of_Human_Resources,_as applicable) and promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by (insert_name_of_child-placing_agency_or Department_of_Human_Resources,_as_applicable) in thus providing for the child, I do relinquish all right, title, and claim to the child herein named, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.

Furthermore, I hereby agree that the (insert_name_of_child-placing agency_or_Department_of_Human_Resources,_as_applicable) may seek for the child a legal adoption by such person or persons as may be chosen by the (insert_name_of_child-placing_agency_or_Department of_Human_Resources,_as_applicable) or its authorized agents, without further notice to me. I do, furthermore, expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.

Furthermore, I understand that under Georgia law the Department of Human Resources or the child-placing agency is required to conduct an investigation and render a report to the court in connection with the legal proceeding for the legal adoption of the child and I hereby agree to cooperate fully with such department or agency in the conduct of its investigation.

Furthermore, I hereby certify that I have received a copy of this document and that I understand I may only withdraw this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to (insert_name and_address_of_child-placing_agency_or_Department_of_Human Resources,_as_applicable) within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof, however, if the tenth day falls on a Saturday, Sunday, or legal holiday then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and I understand that it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this surrender document and do so freely and voluntarily.

Witness my hand and seal this _______ day of ______________, ____.

______________(SEAL) (Parent or guardian)

__________________ Unofficial witness

_____________ Notary public

(b) Reserved.

(c) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-5 shall conform substantially to the following form:

SURRENDER OF RIGHTS FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are surrendering all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You are to receive a copy of this document and as explained below have the right to withdraw your surrender within ten days from the date you sign it.

______________

I, the undersigned, being solicitous that my (male) (female) child, born (insert_name_of_child), on (insert_birthdate_of child), should receive the benefits and advantages of a good home, to the end that (she) (he) may be fitted for the requirements of life, consent to this surrender.

I, the undersigned, (insert_relationship_to_child) of the aforesaid child, do hereby surrender the child to (insert_name, surname_not_required,_of_each_person_to_whom_surrender_is_made), PROVIDED each such person is named as petitioner in a petition for adoption of the child filed in accordance with Chapter 8 of Title 19 of the Official Code of Georgia Annotated within 60 days from the date hereof. Furthermore, I promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by (insert_name,_surname not_required,_of_each_person_to_whom_surrender_is_made) in thus providing for the child, I do relinquish all right, title, and claim to the child herein named, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.

It is also my wish, intent, and purpose that if each such person is not named as petitioner in a petition for adoption as provided for above within the 60 day period, other than for excusable neglect, or, if said petition for adoption is filed within 60 days but the adoption action is dismissed with prejudice or otherwise concluded without an order declaring the child to be the adopted child of each such person, then I do hereby surrender the child as follows:

(Mark one of the following as chosen)

____ I wish the child returned to me, and I expressly acknowledge that this provision applies only to the limited circumstance that the child is not adopted by the person or persons designated herein and further that this provision does not impair the validity, absolute finality, or totality of this surrender under any circumstance other than the failure of the designated person or persons to adopt the child and that no other provision of this surrender impairs the validity, absolute finality, or totality of this surrender once the revocation period has elapsed; or

____ I surrender the child to (insert_name_of_designated licensed_child-placing_agency), a licensed child-placing agency, for placement for adoption; or

_____ I surrender the child to the Department of Human Resources, as provided by subsection (k) of Code Section 19-8-5, for placement for adoption; and (insert_name_of_designated licensed_child-placing_agency) or the Department of Human Resources may petition the superior court for custody of the child in accordance with the terms of this surrender.

Furthermore, I hereby agree that the child is to be adopted either by each person named above or by any other such person as may be chosen by the (insert_name_of_designated_licensed_child-placing agency) or the Department of Human Resources and I do expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.

Furthermore, I understand that under Georgia law an agent appointed by the court is required to conduct an investigation and render a report to the court in connection with the legal proceeding for the legal adoption of the child and I hereby agree to cooperate fully with such agent in the conduct of this investigation.

Furthermore, I hereby certify that I have received a copy of this document and that I understand I may only withdraw this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to (insert_name and_address_of_agent_of_each_person_to_whom_surrender_is_made) within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof; however, if the tenth day falls on a Saturday, Sunday, or legal holiday then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and I understand that it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this surrender document and do so freely and voluntarily.

Witness my hand and seal this ______ day of ______________, ____.

______________(SEAL) (Parent or guardian)

__________________ Unofficial witness

Sworn to and subscribed before me this ______ day of ______________, ____.

_______________________ Notary public (SEAL)

My commission expires ______________.

(d) The surrender of rights by a biological father who is not the legal father of the child pursuant to paragraph (2) of subsection (e) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

SURRENDER OF RIGHTS FINAL RELEASE FOR ADOPTION

NOTICE TO ALLEGED BIOLOGICAL FATHER:

This is an important legal document and by signing it you are surrendering all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You are to receive a copy of this document and as explained below have the right to withdraw your surrender within ten days from the date you sign it.

_______________

I, the undersigned, alleged biological father of a (male) (female) child, born (insert_name_of_child) to (insert_name_of_mother) on (insert_birthdate_of_child), being solicitous that said child should receive the benefits and advantages of a good home, to the end that (she) (he) may be fitted for the requirements of life, consent to this surrender.

I, the undersigned, do hereby surrender the child. I promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits provided to the child through adoption, I do relinquish all right, title, and claim to the child herein named, it being my wish, intent, and purpose to relinquish absolutely all control over the child.

Furthermore, I hereby agree that the child is to be adopted and I do expressly waive any other notice or service in any of the legal proceedings for the adoption of the child. Furthermore, I understand that under Georgia law an agent appointed by the court is required to conduct an investigation and render a report to the court in connection with the legal proceeding for the legal adoption of the child and I hereby agree to cooperate fully with the agent appointed by the court in the conduct of this investigation.

Furthermore, I hereby certify that I have received a copy of this document and that I understand I may only withdraw this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to (insert_name and_address_of_child-placing_agency_representative,_Department_of Human_Resources_representative,_person_to_whom_surrender_is_made, or_petitioner's_representative,_as_appropriate) within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof; however, if the tenth day falls on a Saturday, Sunday, or legal holiday then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and I understand that it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this surrender document and do so freely and voluntarily.

Witness my hand and seal this ______ day of ______________, ____.

______________________(SEAL) (Alleged biological father)

__________________ Unofficial witness

Sworn to and subscribed before me this _____ day of ______________, ____.

____________________________ Notary public (SEAL)

My commission expires ______________.

(e) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-6 or 19-8-7 shall conform substantially to the following form:

SURRENDER OF RIGHTS FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it you are surrendering all of your right, title, and claim to the child identified herein, so as to facilitate the child's placement for adoption. You are to receive a copy of this document and as explained below have the right to withdraw your surrender within ten days from the date you sign it. ______________________

I, the undersigned, being solicitous that my (male) (female) child, born (insert_name_of_child), on (insert_birthdate_of child), should receive the benefits and advantages of a good home, to the end that (she) (he) may be fitted for the requirements of life, consent to this surrender.

I, the undersigned, (insert_relationship_to_child) of the aforesaid child, do hereby surrender the child to (insert_name_of each_person_to_whom_surrender_is_made) and promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by (insert_name of_each_person_to_whom_surrender_is_made) in thus providing for the child, I do relinquish all right, title, and claim to the child herein named, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.

Furthermore, I hereby agree that (insert_name_of_each_person_to whom_surrender_is_made) may initiate legal proceedings for the legal adoption of the child without further notice to me. I do, furthermore, expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.

Furthermore, I understand that under Georgia law the Department of Human Resources may be required to conduct an investigation and render a report to the court in connection with the legal proceeding for the legal adoption of the child and I hereby agree to cooperate fully with the department in the conduct of its investigation.

Furthermore, I hereby certify that I have received a copy of this document and that I understand I may only withdraw this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to (insert_name and_address_of_each_person_to_whom_surrender_is_made) within ten days from the date hereof; that the ten days shall be counted consecutively beginning with the day immediately following the date hereof, however, if the tenth day falls on a Saturday, Sunday, or legal holiday then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday; and I understand it may NOT be withdrawn thereafter.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this surrender document and do so freely and voluntarily.

Witness my hand and seal this ______ day of ______________, ____.

______________(SEAL) (Parent or guardian)

__________________ Unofficial witness

_____________ Notary public

(f) Reserved. (g) The acknowledgment of surrender of rights pursuant to subsection (f) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

ACKNOWLEDGMENT OF SURRENDER OF RIGHTS

By execution of this paragraph, the undersigned expressly acknowledges:

(A) That I have read the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION relating to said minor child born (insert name_of_child), a (male) (female) on (insert_birthdate_of child);

(B) That I understand that this is a full, final, and complete surrender, release, and termination of all of my rights to the child;

(C) That I have the unconditional right to revoke the surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to (insert_name and_address_of_each_person_or_entity_to_whom_surrender_is_made) not later than ten days from the date of the surrender and that after such ten-day period I shall have no right to revoke the surrender;

(D) That the ten days shall be counted consecutively beginning with the day immediately following the date the surrender is executed; however, if the tenth day falls on a Saturday, Sunday, or legal holiday then the last day on which the surrender may be withdrawn shall be the next day that is not a Saturday, Sunday, or legal holiday;

(E) That I have read the accompanying surrender and received a copy thereof;

(F) That any and all questions regarding the effect of said surrender and its provisions have been satisfactorily explained to me;

(G) That I have been afforded an opportunity to consult with counsel of my choice prior to execution of the surrender; and

(H) That the surrender of my rights has been knowingly, intentionally, freely, and voluntarily made by me.

Witness my hand and seal this ______ day of ______________, ____.

_______________(SEAL) (Parent, guardian, or biological father) __________________ Unofficial witness

__________________ Notary public

(h) The affidavit of a legal mother required by subsection (g) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 shall meet the following requirements:

(1) The affidavit shall set forth:

(A) Her name;

(B) Her relationship to the child;

(C) Her age;

(D) Her marital status;

(E) The identity and last known address of any spouse or former spouse;

(F) The identity, last known address, and relationship to the mother of the biological father of her child, provided that the mother shall have the right not to disclose the name and address of the biological father of her child should she so desire;

(G) Whether or not the biological father of the child has lived with the child, contributed to its support, provided for the mother's support or medical care during her pregnancy or during her hospitalization for the birth of the child, or made an attempt to legitimate the child; and

(H) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of the child, or the placement or arranging for the placement of the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the mother need only state the nature of the assistance received; and

(2) The affidavit shall conform substantially to the following form:

MOTHER'S AFFIDAVIT

NOTICE TO MOTHER:

This is an important legal document which deals with your child's right to have its father's rights properly determined. If you decline to disclose the name and address of the biological father of your child, understand that you may be required to appear in court to explain your refusal and that your name may be used in connection with the publication of notice to the biological father. Understand that you are providing this affidavit under oath and that the information provided will be held in strict confidence and will be used only in connection with the adoption of your child.

STATE OF GEORGIA

COUNTY OF ________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, _______________________, who, after having been sworn, deposes and says as follows:

That my name is _______________________.

That I am the mother of a (male) (female) child born (insert name_of_child) in the State of ________, County of ________ on (insert_birthdate_of_child).

That I am ________ years of age, having been born in the State of ________, County of ________ on ______________.

That my social security account number is ________________.

That my marital status at the time of the conception of my child was (check the status and complete the appropriate information):

( ) Single, never having been married.

( ) Separated but not legally divorced; the name of my spouse is _______________________; his last known address is _______________________; we were married in the State of ________, County of ________ on ________; we have been separated since ______________; we last had sexual relations on __________.

( ) Divorced; the name of my previous spouse is _______________________; we were married in the State of ________, County of ________ on ________; his last known address is ______________; divorce granted in the State of __________, County of ________ on ______________.

( ) Legally married; the name of my spouse (was)(is) ______________; we were married in the State of ________, County of ________ on ______________; and his last known address is ______________.

( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) ___________________; his last known address is ______________; our relationship began in the State of _______, County of _______ on _______.

( ) Widowed; the name of my deceased spouse was _______________________; we were married in the State of ________, County of ________ on ________; and he died on ________ in the County of ________, State of ________.

That my name and marital status at the time of the birth of my child was (check the status and complete the appropriate information):

Name _________________________________________________

( ) Single, never having been married.

( ) Separated, but not legally divorced; the name of my spouse (was) (is) ______________________; his last known address is ___________________________; we were married in the State of ________________, County of ______________ on ______________________; we have been separated since ____________________; we last had sexual relations on ______________.

( ) Divorced; the name of my former spouse is ______________; we were married in the State of ______________________, County of ______________ on ______________; his last known address is ___________________________; divorce granted in the State of ________________, County of ______________.

( ) Legally Married; the name of my spouse (was) (is) ___________________; we were married in the State of ____________________, County of ______________ on _________________ on _________________; and his last known address is __________________________.

( ) Married through common-law relationship prior to January 1, 1997; the name of my spouse (was)(is) ______________; his last known address is ______________; our relationship began in the State of ______________, County of ______________ on ______________.

( ) Widowed; the name of my deceased spouse was _____________; we were married in the State of ________, County of ______________ on ______________; and he died on ______________ in the County of ______________, State of ______________.

That the name of the biological father of my child is (complete appropriate response):

Known to me and is (________________);

Known to me but I expressly decline to identify him because ________________________________; or

Unknown to me because ____________________________________________________________ ___________________________________________________________.

That the last known address of the biological father of my child is (complete appropriate response):

Known to me and is ________________________________________;

Known to me but I expressly decline to provide his address because ________________________________; or

Unknown to me because ____________________________________________________________ ___________________________________________________________.

That, to the best of my knowledge, I (am) (am not) of American Indian heritage. If so:

(A) The name of my American Indian tribe is ______________ and the percentage of my American Indian blood is ______ percent. (B) My relatives with American Indian blood are: ____________________________________________________________ ____________________________________________________________ ___________________________________________________________.

(C) I (am) (am not) a member of an American Indian tribe. If so, the name of the tribe is ____________________.

(D) I (am) (am not) registered with an American Indian tribal registry. If so, the American Indian tribal registry is: _______________________ and my registration or identification number is: ____________________________.

(E) A member of my family (is) (is not) a member of an American Indian tribe. If so, the name of each such family member is: ___________________ and the name of the corresponding American Indian tribe is: ____________________________.

(F) A member of my family (is) (is not) registered with an American Indian tribal registry. If so, the name of each such family member is: __________________________________________________ and the name of the corresponding American Indian tribal registry is: _____________________________ and their corresponding registration or identification numbers are:____________________.

That to the best of my knowledge, the biological father (is) (is not) of American Indian heritage. If so:

(A) The name of his American Indian tribe is ______________ and the percentage of his American Indian blood is ______ percent.

(B) His relatives with American Indian blood are: ____________________________________________________________ ____________________________________________________________ ___________________________________________________________.

(C) He (is) (is not) a member of an American Indian tribe. If so, the name of the tribe is:______________________________.

(D) He (is) (is not) registered with an American Indian tribal registry. If so, the American Indian tribal registry is: ______________________ and his registration or identification number is: ______________________________________________.

That the date of birth of the biological father (was _____________, ____) or (is not known to me).

That the biological father (is) (is not) on active duty in a branch of the United States armed forces. If so:

(A) The branch of his service is (Army) (Navy) (Marine) (Air Force) (Coast Guard).

(B) His rank is __________. (C) His duty station is ____________________.

If applicable, please provide any additional available information regarding his military service. ____________________________________________________________ ____________________________________________________________ ___________________________________________________________.

That the biological father of my child, whether or not identified herein (strike each inappropriate phrase):

(Was) (Was not) married to me at the time this child was conceived;

(Was) (Was not) married to me at any time during my pregnancy with this child;

(Was) (Was not) married to me at the time that this child was born;

(Did) (Did not) marry me after the child was born and recognize the child as his own;

(Has) (Has not) been determined to be the child's father by a final paternity order of a court;

(Has) (Has not) legitimated the child by a final court order;

(Has) (Has not) lived with the child;

(Has) (Has not) contributed to its support;

(Has) (Has not) provided for my support during my pregnancy or hospitalization for the birth of the child;

(Has) (Has not) provided for my medical care during my pregnancy or hospitalization for the birth of the child; and

(Has) (Has not) made any attempt to legitimate the child.

That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with my pregnancy, the birth of my child, and its placement for adoption: ____________________________________.

That I recognize that if I knowingly and willfully make a false statement in this affidavit, I will be guilty of the crime of false swearing.

______________________ (Biological mother's signature) Sworn to and subscribed before me this ________ day of ______________, ____. ___________________________ Notary public (SEAL) My Commission Expires _____________. (i) The affidavit of an adoptive mother required by subsection (a) of Code Section 19-8-9 for the surrender of her rights shall meet the following requirements:

(1) The affidavit shall set forth:

(A) Her name;

(B) Her relationship to the child;

(C) Her age;

(D) Her marital status;

(E) The name and last known address of any spouse at the time the child was adopted and whether any such spouse also adopted the child or was the biological father of the child;

(F) The circumstances surrounding her adoption of her child, including the date the adoption was finalized, the state and county where finalized, and the name and address of the adoption agency, if any; and

(G) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with the placement or arranging for the placement of her child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by the adoptive mother's husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead the adoptive mother need only state the nature of the assistance received.

(2) The affidavit shall be in substantially the following form:

ADOPTIVE MOTHER'S AFFIDAVIT

NOTICE TO MOTHER:

This is an important legal document which deals with your child's right to have its legal father's rights properly terminated. Understand that you are providing this affidavit under oath and that the information provided will be held in strict confidence and will be used only in connection with the adoption of your child.

STATE OF GEORGIA COUNTY OF ________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________, who, after having been sworn, deposes and says as follows:

That my name is _____________________________________________.

That I am the adoptive mother of a (male) (female) child born (insert_name_of_child) in the State of ________, County of ________ on (insert_birthdate_of_child).

That I am ________ years of age, having been born in the State of ________, County of ________ on ______________. That my marital status is (check the status and complete the appropriate information):

( ) Single, never having been married.

( ) Separated but not legally divorced; the name of my spouse is ______________; his last known address is ______________; we were married in the State of ________, County of ________ on ______________; we have been separated since ______________; my spouse (did) (did not) also adopt said child; my spouse (is) (is not) the biological father of said child.

( ) Divorced; the name of my previous spouse is ______________; we were married in the State of ________, County of ________ on ______________; his last known address is ______________; divorce granted in the State of ________, County of ________ on ______________; my previous spouse (did) (did not) also adopt said child; my previous spouse (is) (is not) the biological father of said child.

( ) Legally married; the name of my spouse is ______________; we were married in the State of ________, County of ________ on ______________; his last known address is ______________; my spouse (did) (did not) also adopt said child; my spouse (is) (is not) the biological father of said child.

( ) Married through common-law marriage relationship; the name of my spouse is ______________; his address is ______________; the date and place our relationship began is (date,_county,_state); my spouse (did) (did not) also adopt said child; my spouse (is) (is not) the biological father of said child.

( ) Widowed; the name of my deceased spouse is ______________; we were married in the State of ________, County of ________ on ________; he died on ______________ in the County of ________, State of ________; he (did) (did not) also adopt said child; and he (was) (was not) the biological father of said child.

That I adopted my child in the State of ________, County of ________;

That the final order of adoption was entered on ______________;

That there (was) (was not) an adoption agency involved in the placement of my child with me for adoption; and if so its name was _______________________, and its address is _______________________.

That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with my child's placement for adoption: ______________.

That I recognize that if I knowingly and willfully make a false statement in this affidavit, I will be guilty of the crime of false swearing.

_________________ (Adoptive mother) Sworn to and subscribed before me this ________ day of __________, ____. _____________ Notary public

(j) The affidavit of an agency or department representative required by subsection (h) of Code Section 19-8-4 shall conform substantially to the following form:

AFFIDAVIT OF AGENCY OR DEPARTMENT REPRESENTATIVE

Personally appeared before me, the undersigned officer duly authorized to administer oaths, _______________________, who, after having been sworn, deposes and says as follows:

That I am (position) of (department or agency).

That prior to the execution of the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION by __________________________, releasing and surrendering all of (his) (her) rights in a (male) (female) minor child born (insert_name_of_child) on (insert birthdate_of_child), I reviewed with and explained to said individual all of the provisions of the surrender, and particularly the provisions which provide that the surrender is a full surrender of all rights to the child.

That based on my review and explanation to said individual, it is my opinion that said individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

_______________________ (Agency representative) Sworn to and subscribed before me this ______ day of ______________, ____. _____________ Notary public

(k) The affidavit of a petitioner's representative required by subsection (h) of Code Section 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

AFFIDAVIT OF PETITIONER'S REPRESENTATIVE

Personally appeared before me, the undersigned officer duly authorized to administer oaths, _______________________, who, after having been sworn, deposes and says as follows:

That my name is ________________________.

That my address is _______________________.

That prior to the execution of the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION by __________________________, releasing and surrendering all of (his) (her) rights in a (male) (female) minor child born (insert_name_of_child) on (insert birthdate_of_child), I reviewed with and explained to said individual all of the provisions of the surrender, and particularly the provisions which provide that the surrender is a full surrender of all rights to the child.

That based on my review and explanation to said individual, it is my opinion that said individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

_____________________________ (Petitioner's representative) Sworn to and subscribed before me this ______ day of ______________, ____. _____________ Notary public

(l) The parental consent to a stepparent adoption required by subsection (j) of Code Section 19-8-6 shall conform substantially to the following form:

PARENTAL CONSENT TO STEPPARENT ADOPTION

I, the undersigned, hereby consent that my spouse (insert_name_of spouse) adopt my (son) (daughter), (insert_name_of_child), whose date of birth is ______________, and in so doing I in no way relinquish or surrender my parental rights to the child.

I further acknowledge service of a copy of the petition for adoption of the child as filed on behalf of my spouse, and I hereby consent to the granting of the prayers of the petition. I also waive all other and further service and notice of any kind and nature in connection with the proceedings.

This ______ day of ______________, ____.

_______________ (Parent) __________________ Unofficial witness

_____________ Notary public