■
■
■ ■
■ ■
■ ■
■ ■
_________________________________________________
■
_________________________________________________
________________________________________________________
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
NOTICE OF REMOVAL OF CHILD FROM ADOPTIVE HOME
TO: California Department of Social Services
Adoptions Services Bureau
744 P Street, M.S. 8-12-31
Sacramento, California 95814
State Case Number
___________________________________________________________________
born
________________________________________was
NAME OF CHILD BIRTHDATE
removed from the home of_________________________________________________________________________________________
_and
NAME OF APPLICANT
_______________________________________________________
at_________________________________________________________
NAME OF APPLICANT
on_______________________________________________.
DATE
Date of Placement________________________________________ AAP Placement:
■ Yes
■■ No
■■ No
REASON FOR REMOVAL:
(Check the most significant reason)
1. ■ Child behavior problem
2.
■ Marital problems
3.
■ Financial problems
4.
■ Parenting problems
(Child removed by agency)
5.
■ Parenting problems
(Child removed at request of parent(s))
ADDRESS
6.
■ Return to permanent foster care
7.
■ Death of parent(s)
8.
■ Death of child
9.
■ Other (specify)_____________________________________
(NAME OF AGENCY)
By ______________________________________________________
Date_____________________________
AD 580 (7/10)
