Ga. Code § 19-8-26
"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 rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 5, you have the right to revoke this surrender within four days from the date you sign it.
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:
I, the undersigned, being mindful that my (male) (female) [circle one] child, born __________________ (name of child) on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.
I, the undersigned, __________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to __________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, 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 __________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child. Furthermore, I hereby agree that the __________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) may seek for the child a legal adoption by such individual or individuals as may be chosen by the __________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, 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.
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 its investigation.
I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.
I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to __________________ (name and address of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to __________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.
I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.
Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.
This __________________ day of __________________, __________________.
__________________(Parent or guardian)
__________________
Adult witness
Sworn to and subscribed
before me this __________________
day of __________________, __________________.
__________________
Notary Public (SEAL)
My commission expires: __________________."
"NOTICE TO REVOKE SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION
I, the undersigned, executed a (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] as to the child identified in the surrender of rights document on __________________ (date). My relationship to the (child) (unborn child) [circle one] is that I am the (mother) (father) (alleged biological father) (guardian) [circle one].
(Complete this paragraph if the child has been born.) This notice to revoke my surrender of rights applies to the (female) (male) [circle one] child born __________________ (name of child) on __________________ (birthdate of child).
I now wish to exercise my right to revoke my surrender of rights.
I understand that for my revocation of surrender to be effective I must:
OR
This __________________ day of __________________, __________________.
__________________(Parent, guardian, or alleged biological father)
__________________(Printed name)__________________Adult witness"
"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 rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 8, you have the right to revoke this surrender within four days from the date you sign it.
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:
I, the undersigned, being mindful that my (male) (female) [circle one] child, born __________________ (name of child) on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.
I, the undersigned, __________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to __________________ (name, surname not required, of each individual to whom surrender is made), PROVIDED that each such individual is named as petitioner in a petition for adoption of the child filed in accordance with Article 1 of Chapter 8 of Title 19 of the Official Code of Georgia Annotated within 60 days from the date that I sign this document. Furthermore, I promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by __________________ (name, surname not required, of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, 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 individual identified in paragraph 2 is not named as petitioner in a petition for adoption within the 60 day period, other than for justifiable good cause, or, if said petition for adoption is filed within 60 days but the adoption proceeding is dismissed with prejudice or otherwise concluded without an order declaring the child to be the adopted child of each such individual, then I do hereby surrender my rights to the child as follows:
Indicate your choice by signing ONE of the following statements (you may choose statement A, B, or C):
OR
OR
I hereby agree that the child is to be adopted by each individual named in paragraph 2 or by any other individual as may be chosen by __________________ (name of child-placing agency or out-of-state licensed agency) or the Department of Human Services and I do expressly waive any other notice or service in any of the legal proceedings for the adoption of the child.
I understand that under Georgia law an evaluator is required to conduct and provide to the court a home study and make recommendations to the court regarding the qualification of each individual named in paragraph 2 to adopt the child concerning the circumstances of placement of the child for adoption.
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 its investigation.
I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.
I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to __________________ (name and address of each individual to whom surrender is made or his or her agent) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to __________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.
I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.
Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.
This __________________ day of __________________, __________________.
__________________(Parent or guardian)
__________________Adult witness
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary Public (SEAL)
My commission expires: __________________."
"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 rights to the child identified in this document. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 4, you have the right to revoke this surrender within four days from the date you sign it.
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows:
I, the undersigned, alleged biological father of a (male) (female)
[circle one] child, born __________________ (name of child)
to __________________ (name of legal mother) on
__________________ (birthdate of child) at
__________________:__________________(A.M.) (P.M.) [circle one], being mindful that
the child should receive the benefits and advantages of a good home,
to the end that (she) (he) [circle one] may be fitted for the require-
ments of life, consent to this surrender of my rights. I, the undersign-
ed, do hereby surrender my rights to the child. I promise not to inter-
fere 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 rights to the child named in this document, it being
my wish, intent, and purpose to relinquish absolutely all control over
the child.
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. 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 its investigation.
I understand that I will receive a copy of this document after the
witness and I have signed it and it has been notarized.
I understand that under Georgia law I have the unconditional right
to a four-day revocation period. I understand I may only revoke this
surrender by giving written notice, delivered in person or mailed by
registered mail or statutory overnight delivery, to
__________________ (name and address of child-placing
agency representative, out-of-state licensed agency representative,
Department of Human Services representative, individual to whom
surrender is made or his or her agent, or petitioner's representative,
as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail
delivery of the notice to revoke this surrender. I understand that the
four days will be counted consecutively beginning with the day
immediately following the date I sign this document; provided,
however, that, if the fourth day falls on a Saturday, Sunday, or legal
holiday, then the last day on which this surrender may be revoked
will be the next day that is not a Saturday, Sunday, or legal holiday.
I understand that, if I deliver the notice to revoke this surrender in
person, it must be delivered to __________________ (name
and address) not later than 5:00 P.M. eastern standard time or
eastern daylight time, whichever is applicable, on the fourth day;
provided, however, that if I mail the notice by registered mail or have
it delivered by statutory overnight delivery, I must address it to the
address shown in the surrender document and submit it to the
United States Postal Service or to the statutory overnight delivery
carrier not later than 12:00 Midnight eastern standard time or
eastern daylight time, whichever is applicable, on the fourth day. I
understand that I CANNOT revoke this surrender after that time.
I understand that if I am not a resident of this state that I am
agreeing to be subject to the jurisdiction of the courts of Georgia for
any action filed in connection with the adoption of the child. I agree
to be bound by a decree of adoption rendered as a result of this
surrender of my parental rights.
Furthermore, I hereby certify that I have not been subjected to any
duress or undue pressure in the execution of this document and I am
signing it freely and voluntarily.
This __________________ day of __________________, __________________.
__________________(Alleged biological father)
__________________Adult witness
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"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 rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this surrender within four days from the date you sign it.
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:
I, the undersigned, being mindful that my (male) (female) [circle one] child, born __________________ (name of child) on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.
I, the undersigned, __________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to __________________ (name of each individual 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 __________________ (name of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.
I hereby agree that __________________ (name of each individual 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.
I understand that under Georgia law an agent may be appointed by the court 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 its investigation.
I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.
I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to __________________ (name and address of each individual to whom surrender is made or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to __________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.
I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.
Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.
This __________________ day of __________________, __________________.
__________________(Parent or guardian)
__________________Adult witness
Sworn to and subscribed
before me this __________________
day of __________________, __________________.
__________________Notary public (SEAL)My commission expires: __________________."
"PRE-BIRTH 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 any and all of your rights to the child identified in this document, so as to place the child for adoption. You have the right to wait to execute a SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION after the child is born, but by signing this document, you are electing to surrender your rights prior to the birth of this child. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this pre-birth surrender within four days from the date you sign it.
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows:
I, the undersigned, understand that I have been named by __________________, the biological mother of the child expected to be born in __________________ (city) __________________ (county) __________________ (state) on or about the __________________ day of __________________ (month), __________________ (year), as the biological father or possible biological father of her child. I further understand that the biological mother wishes to place this child for adoption.
To the best of my knowledge and belief, the child has not been born as of the date I am signing this pre-birth surrender; however, if in fact the child has been born, this surrender shall have the same effect as if it were a surrender executed following the birth of the child.
I understand that by signing this document I am not admitting that I am the biological father of this child, but if I am, I hereby agree that adoption is in this child's best interest. I consent to adoption of this child by any individual chosen by the child's legal mother or by any public or private agency that places children without further notice to me. I expressly waive any other notice or service in any of the legal proceedings for the adoption of the child. I understand that I have the option to wait until after the child is born to execute a surrender of my rights (with a corresponding four-day right of revocation) and, further, that by executing this document I am electing instead to surrender my rights before the child's birth.
I understand that signing this document does not fully and finally terminate my rights and responsibilities until an order from a court of competent jurisdiction terminating my rights or a final order of adoption is entered. I understand that if the child is not adopted after I sign this document, legal proceedings can be brought to establish paternity, and I may become liable for financial obligations related to the birth and support of this child.
I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.
I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand that I may only revoke this pre-birth surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to __________________ (name and address of child-placing agency representative, out-of-state licensed agency representative, Department of Human Services representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this pre-birth surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to __________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.
If prior to my signing this pre-birth surrender I have registered on Georgia's putative father registry then, if I do not revoke this surrender within the time permitted, I waive the notice I would be entitled to receive pursuant to Code Section 19-8-12 of the Official Code of Georgia Annotated because of my registration on the putative father registry.
I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.
Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.
This __________________ day of __________________, __________________.
__________________ (Alleged biological father)
__________________
Adult witness
Sworn to and subscribed
before me this __________________ day of
__________________, __________________.
__________________
__________________
Notary public (SEAL)
My commission expires: __________________."
"ACKNOWLEDGMENT OF SURRENDER
OF RIGHTS
__________________
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent, guardian, or alleged biological father) who, after having been sworn, deposes and says as follows:
DER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (SURREND-
ER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one]
relating to the child born __________________ (name of child), a
(male) (female) [circle one] on __________________ (birthdate of child);
surrender, release, and termination of all of my rights to the child;
by giving written notice, delivered in person or mailed by registered
mail or statutory overnight delivery, to __________________
(name and address of child-placing agency or its representative,
out-of-state licensed agency or its representative, Department of
Human Services or its representative, individual to whom surrender
is made or his or her agent, or petitioner's representative, as applic-
able) within four days from the date of signing the surrender and
that after such four-day revocation period I shall have no right to re-
voke the surrender. I understand that certified mail cannot be used
for mail delivery of the notice to revoke the surrender of my rights.
I understand that, if I deliver the notice to revoke my surrender in
person, it must be delivered to __________________ (name
and address) not later than 5:00 P.M. eastern standard time or
eastern daylight time, whichever is applicable, on the fourth day;
provided, however, that if I mail the notice by registered mail or
have it delivered by statutory overnight delivery, I must address it
to the address shown in the surrender document and submit it to
the United States Postal Service or to the statutory overnight deli-
very carrier not later than 12:00 Midnight eastern standard time or
eastern daylight time, whichever is applicable, on the fourth day. I
understand that the four days will be counted consecutively
beginning with the day immediately following the date I signed
the surrender; provided, however, that, if the fourth day falls
on a Saturday, Sunday, or legal holiday, then the last day on that
is which the surrender may be revoked will be the next day
not a Saturday, Sunday, or legal holiday;
received a copy thereof;
surrender and its provisions have been satisfactorily explained
to me;
attorney of my choice before signing the surrender of my rights;
and
intentionally, freely, and voluntarily made by me.
This __________________ day of __________________, __________________.
__________________(Parent, guardian, or alleged biological father)
__________________Adult witness
Sworn to and subscribedbefore me this __________________ day of__________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"LEGAL MOTHER'S AFFIDAVIT
NOTICE TO LEGAL MOTHER:
This is an important legal document which deals with the child's right to have his or her biological father's rights properly determined. You have the right not to disclose the name and address of the biological father of the child. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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 legal mother of a (male) (female) [circle one] child born __________________ (name of child) in the State of __________________, County of __________________ on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one].
That I am __________________ years of age, having been born in the State of __________________, County of __________________ on __________________.
That my social security number is __________________.
That my marital status at the time of the conception of the 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 (was) (is) [circle one] __________________; my spouse's 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 __________________ (date); my spouse (is) (is not) [circle one] the biological father of said child.
() Divorced; the name of my former spouse is __________________; we were married in the State of __________________, County of __________________ on __________________; we last had sexual relations on __________________ (date); my former spouse's last known address is __________________; divorce granted in the State of __________________, County of __________________ on __________________; my former spouse (is) (is not) [circle one] the biological father of said child.
() Legally married; the name of my spouse (was) (is) [circle one] __________________; we were married in the State of __________________, County of __________________ on __________________; and my spouse's last known address is __________________; my spouse (is) (is not) [circle one] the biological father of said child.
() Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] __________________; my spouse's last known address is __________________; our relationship began in the State of __________________, County of __________________ on __________________; my spouse (is) (is not) [circle one] the biological father of said child.
() Widowed; the name of my deceased spouse was __________________; we were married in the State of __________________, County of __________________ on __________________; my spouse died on __________________ in the County of __________________, State of __________________.
That my name and marital status at the time of the birth of the 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) [circle one] __________________; my spouse's 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 __________________ (date); my spouse (is) (is not) [circle one] the biological father of said child.
() Divorced; the name of my former spouse is __________________; we were married in the State of __________________, County of __________________ on __________________; we last had sexual rela-tions on __________________ (date); my spouse's last known address is __________________; divorce granted in the State of __________________, County of __________________; my former spouse (is) (is not) [circle one] the biological father of said child.
() Legally married; the name of my spouse (was) (is) [circle one] __________________; we were married in the State of __________________, County of __________________ on __________________; my spouse's last known address is __________________; my spouse (is) (is not) [circle one] the biological father of said child.
() Married through common-law relationship prior to Janu-ary 1, 1997; the name of my spouse (was) (is) [circle one] __________________; my spouse's last known address is __________________; our relationship began in the State of __________________, County of __________________ on __________________; my spouse (is) (is not) [circle one] the biological father of said child.
() Widowed; the name of my deceased spouse was __________________; we were married in the State of __________________, County of __________________ on __________________; my spouse died on __________________ in the County of __________________, State of __________________; he (was) (was not) [circle one] the biological father of said child.
That the name of the biological father of the 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 the 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) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so:
That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so:
__________________
__________________.
That, to the best of my knowledge, the biological father or a member of his family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so:
__________________
__________________.
That the date of birth of the biological father (is __________________, __________________) (is not known to me) [circle one].
That the biological father (is) (is not) [circle one] on active duty in a branch of the United States armed forces. If so:
If applicable, please provide any additional available informa-tion regarding his military service.
__________________
__________________
__________________.
That the biological father of the child, whether or not identified in this document (circle the appropriate 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 preg-nancy 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 recog-nize 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; and
(Has) (Has not) provided for my medical care during my pregnancy or hospitalization for the birth of the child.
That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is __________________, and the probate court in which the petition for temporary guardianship was filed is __________________.
That custody of the child has been awarded to __________________ (name and address of custodian) by order of the __________________ Court of __________________ County, State of __________________, entered on __________________ (date).
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 the child, and the 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.
__________________
(Legal mother)
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)My commission expires __________________."
"ADOPTIVE MOTHER'S AFFIDAVIT
NOTICE TO ADOPTIVE MOTHER:
This is an important legal document which deals with the adopted child's right to have his or her legal father's rights properly determined. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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) [circle one] child born __________________ (name of child) in the State of __________________, County of __________________ on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one].
That I am __________________ years of age, having been born in the State of __________________, County of __________________ on __________________.
That my social security number is __________________.
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 (was) (is) [circle one] __________________; my spouse's 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 __________________ (date); my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.
() Divorced; the name of my former spouse is __________________; we were married in the State of __________________, County of __________________ on __________________; we last had sexual relations on __________________ (date); my former spouse's last known address is __________________; divorce granted in the State of __________________, County of __________________ on __________________; my former spouse (did) (did not) [circle one] also adopt said child; my former spouse (is) (is not) [circle one] the biological father of said child.
() Legally married; the name of my spouse (was) (is) [circle one] __________________; we were married in the State of __________________, County of __________________ on __________________; my spouse's last known address is __________________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.
() Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] __________________; my spouse's last known address is __________________; our relationship began in the State of __________________, County of __________________ on __________________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.
() Widowed; the name of my deceased spouse was __________________; we were married in the State of __________________, County of __________________ on __________________; my spouse died on __________________ in the County of __________________, State of __________________; he (did) (did not) [circle one] also adopt said child; he (was) (was not) [circle one] the biological father of said child.
That I adopted the child in the State of __________________, County of __________________.
That the final order of adoption was entered on __________________.
That there (was) (was not) [circle one] an adoption agency involved in the placement of the child with me for adoption; and if so its name was __________________, and its address is __________________.
That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is: __________________, and the probate court in which the petition for temporary guardianship was filed is __________________.
That custody of the child has been awarded to __________________ (name and address of custodian) by order of the __________________ Court of __________________ County, State of __________________, entered on __________________ (date).
That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the 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 subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"AFFIDAVIT OF CHILD-PLACING AGENCY,
OUT-OF-STATELICENSED AGENCY, OR
DEPARTMENT REPRESENTATIVE
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 I am __________________ (position) of __________________ (name of department, child-placing agency, or out-of-state licensed agency).
That prior to the execution of the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION by __________________, releasing and surrendering all of (his) (her) [circle one] rights in a (male) (female) [circle one] child born __________________ (name of child) on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.
__________________(Representative) __________________(Department or agency name)
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"AFFIDAVIT OF REPRESENTATIVE
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 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) [circle one] rights in a (male) (female) [circle one] child born __________________ (name of child) on __________________ (birthdate of child) at __________________:__________________ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.
__________________(Petitioner's representative or the
representative of the individual
signing the surrender)Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"PARENTAL CONSENT TO STEPPARENT ADOPTION
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of parent) who, after having been sworn, deposes and says as follows:
I, the undersigned, hereby consent that my spouse __________________ (name of spouse) adopt my (son) (daughter) [circle one], __________________ (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 for adoption. I also waive all other and further service and notice of any kind and nature in connection with the proceedings.
This __________________ day of __________________, __________________.
__________________(Parent)
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
"NOTICE TO BIOLOGICAL MOTHER:
This is an important legal document which will enable the individual you identify as the biological father of your unborn child to sign a pre-birth surrender of his rights so as to place your child for adoption. Understand that you are signing this affidavit under oath and that the information you provide will be held in strict confidence and will be used only in connection with the adoption of your unborn child.
STATE OF GEORGIA
COUNTY OF __________________
BIOLOGICAL MOTHER'S AFFIDAVIT IDENTIFYING
BIOLOGICAL FATHER OF HER UNBORN CHILD
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 __________________ years of age, having been born in the State of __________________, County of __________________ on __________________.
That my social security number is __________________.
That I am currently pregnant with a (male) (female) (sex unknown) [circle one] child who is expected to be born on __________________ (due date of child).
That the name of any alleged biological father is __________________, and his last known address is __________________.
That I execute this affidavit so that any alleged biological father I have identified above can be asked to sign a pre-birth surrender of his rights to assist me in placing the child for adoption once the child is born.
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)
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)My commission expires: __________________."
"NOTICE TO BIOLOGICAL OR LEGAL FATHER:
This is an important legal document. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing.
__________________
AFFIDAVIT REGARDING NATIVE AMERICAN HERITAGE
AND MILITARY SERVICE
STATE OF GEORGIA
COUNTY OF __________________
Personally appeared before me, the undersigned officer duly authorized to administer oaths, __________________ (name of affiant) who, after having been sworn, deposes and says as follows:
__________________
__________________.
__________________
__________________
__________________.
__________________(Biological or legal father)
Sworn to and subscribedbefore me this __________________day of __________________, __________________.
__________________Notary public (SEAL)
My commission expires: __________________."
OCGA § 19-8-26