Fillable STATEMENT OF UNDERSTANDING AGENCY ADOPTIONS PROGRAM (California)

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STATEMENT OF UNDERSTANDING AGENCY ADOPTIONS PROGRAM (California)

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AD 885 (3/14) Mother or a Biological/Presumed Father of a Child who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
Page 1 of 6
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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF UNDERSTANDING
AGENCY ADOPTIONS PROGRAM
Relinquishing a child means permanently giving the child to the adoption agency so the
agency can choose other parent(s) to adopt the child. You permanently give the child to the
adoption agency by signing this Statement of Understanding and the relinquishment
document. You will no longer have any rights as a parent to your child once these documents
have been filed with and acknowledged by the California Department of Social Services.
If you are thought to be a biological/presumed father of the child, you should be aware that
under the law you have legal rights and responsibilities toward the child even if you deny
paternity. You also have a right to look for legal counsel to obtain the right to physical custody
of the child. If you want to be a parent to the child, there are services available to help you.
Giving your child to the adoption agency is a very important decision. You should know all the
facts about it and weigh its advantages and disadvantages before you make your decision.
Instructions To Complete The Statement Of Understanding:
BEFORE YOU SIGN THIS STATEMENT OF UNDERSTANDING AND THE RELINQUISHMENT
DOCUMENT, READ BOTH VERY CAREFULLY WITH YOUR SOCIAL WORKER. BE SURE TO
ASK QUESTIONS ABOUT ANYTHING YOU DO NOT UNDERSTAND.
1. Complete this Statement of Understanding only after you have carefully thought about giving your child to the
adoption agency and you are sure you want your child adopted and raised by prospective adoptive parent(s)
selected by the adoption agency.
2. Read each of the statements in this document very carefully. If you do not understand a statement, ask your social
worker to explain it to you until you do understand.
3. If you understand and agree with a statement, put your initials in the box next to the number of that statement.
4. If you do not agree, or if you do not understand a statement after your social worker’s explanation, do not initial the
box. Ask for more help and time in making your decision.
5. If you have initialed all the boxes, sign your name at the end. Two witnesses must be present when you sign your
name and they will sign their names after yours. (Witnesses are not necessary if this form is signed outside of
California).
6. You will receive a copy of this Statement of Understanding and the relinquishment document once it has been
completed.
This form must be used with one of the following forms:
AD 501, AD 501A, AD 504, AD 583, AD 584, or AD 4339.
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____________________________________________________ .
STATEMENT OF UNDERSTANDING
Name of Child ___________________________________________________________________ Date of Birth ________________
Page 2 of 6
AD 885 (3/14) Mother or a Biological/Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Mother or a Biological/Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian
1 I understand I have the right to look for a lawyer to help me in the relinquishment process and the adoption
agency can refer me to public legal help in my community.
2. I understand the agency is to tell me about its adoption plan for my child.
3. I understand I may talk about my plan to give up my child for adoption to other professional people, my family
and friends.
4. I understand if I sign this Statement of Understanding and the relinquishment document, I shall no longer be
my child’
s legal parent once these documents are filed with and acknowledged b
y the California Department of
Social Services. This means:
A. I shall no longer be responsible for the care of my child; and
B. I shall no longer have any right to the custody, services or earnings of my child.
5. I understand if I am not sure I want to give up my child, there are other places the agency can refer me to that
could help me with family, health, money and other problems
.
6. I understand that by signing the relinquishment I am giving my child to the adoption agency.
A. If I sign a relinquishment that does not name the prospective adoptive parent(s), I am giving up the right to
select the prospective adoptive parent(s) and the final decision about who adopts my child will be made by
the adoption agency
.
I am not naming the prospective adoptive parent(s) for my child.
B. If I sign a relinquishment that names the prospective adoptive parent(s), I am giving my child to the
adoption agency which intends to place my child with the person(s) named on the relinquishment
document.
I am naming the following person(s) as the prospective adoptive parent(s):
If my child is not placed in the home of the named person(s) or my child is removed from the home before
the adoption is completed:
(1) The agency will send me a notice by certified mail, return receipt requested, within 72 hours of the
decision not to place my child for adoption or the decision to remove m
y child from the home. I must
keep the agency informed of my address if I want to receive such a notice.
(2) I shall have 30 days from the date the notice was mailed to me to either:
a. Rescind the relinquishment. The agency will rescind the relinquishment if I deliver, or have
delivered by mail or other means, a written request to rescind the relinquishment to the agency
before the end of the 30-day period, or
b. Take no action. If I take no action during the 30-day period, I shall lose my right to rescind the
relinquishment and the agency will select adoptive parent(s) for my child, or
c. Select another placement for my child. If, during the 30-day period, I select another person(s)
with whom my child is to be placed, I shall rescind the initial relinquishment and complete a new
relinquishment document identifying the person(s) with whom I then wish the agency to place my
child.
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Page 3 of 6
AD 885 (3/14) Mother or a Biological//Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
7. I understand that the prospective adoptive parent(s) and the birth relatives, including the birth parents, may
enter into an enforceable written agreement to permit continuing contact between the birth relatives, including
the birth parents, and the child if the court approves.
8. I understand if I decide not to give my child to the adoption agency, I may place my child for adoption with
parent(s) I find myself and agree only to an adoption of my child by this/these parent(s). This is called an
Independent Adoption.
9. I understand after my child’s adoption has been granted in court, all inheritance rights from any blood relatives
will end unless they have made arrangements in their will or in a trust which specifically includes my child. My
child will legally inherit from his/her prospective adoptive parent(s).
10. I understand if I sign this Statement of Understanding and the relinquishment document, I can take them back
during any holding period referred to in Number 18 below or before it has been filed with and acknowledged by
the California Department of Social Services, unless I also signed a “Waiver of Right To Revoke
Relinquishment” (AD 929A). If I signed a Waiver of Right To Revoke Relinquishment, the relinquishment is
irrevocable immediately or at the close of the next business day as noted on the Waiver in the Section where
“Birth parent must initial one of the following statements:” unless the waiver is void or the relinquishment is
rescinded.
A. Under normal circumstances the adoption agency must return my child to me within three working days
and in no case should it take more than seven calendar days
.
B. The rights and responsibilities as my child’s parent will continue unless taken away by other legal action.
C. If the adoption agency believes returning my child to me would hurt or otherwise harm my child, the
agency will make an immediate referral to the county’s child protective services agency. The adoption
agency will let me know in writing if they do this.
11. I understand once the California Department of Social Services has filed and acknowledged my signed
relinquishment it is final, and
A. I cannot stop the relinquishment and have my child returned to me unless the adoption agency agrees or
unless the prospective adoptive parent(s) is/are named on the relinquishment and my child is not placed
in the named home or my child is removed from the home before the adoption is completed.
B. If the adoption agency does not agree, the adoption agency will inform me in writing of the reason(s) for
not returning my child.
C. If the adoption agency agrees to return my child, the rights and responsibilities as my child’s parent will
continue unless taken away by other legal action.
D. If the adoption agency agrees to return my child, it will normally take three working days and in no case
can it take more than seven calendar days.
12. I understand that if the child is a juvenile court dependent or the subject of a petition for juvenile court
jurisdiction, the adoption agency must provide written notification to the juvenile court, the child’s lawyer, and
my lawyer, if any, of the relinquishment within five court days.
13. I understand before my child is legally adopted, the adoption agency must answer my questions about his/her
situation. If I ask for information at any future time, the agency must give me all known information about the
status of my child’s adoption, including whether my child has been placed for adoption, the approximate date
the adoption was completed and, if the adoption was not completed or was vacated for any reason, whether
adoptive placement of my child is again being considered.
A. I understand I must keep the adoption agency informed of my address if I want to know when my child
was placed in an adoptive home and when my child was legally adopted.
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Page 4 of 6
AD 885 (3/14) Mother or a Biological/Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
14. I understand after my child has been legally adopted, the adoption agency may not return my child to me.
15. I understand the adoption agency may release identifying information from the adoption case record only
when:
A. It has been requested by certain agencies as named in law because the information is needed to help my
child.
B. My child, when he/she is an adult, and I have signed forms agreeing to the release of identifying
information so contact may be arranged.
C. My child has reached 21 years of age, asks for my identity and I have agreed in writing to the release of
my identity and most current address in the adoption agency’s record.
D. My child has reached 21 years of age and has indicated in writing I can have his/her adopted name and
most current address as indicated in the adoption agency’s record and I have asked for this information,
or
E. My child is under 21 years of age and the adoption agency has found the release of my identity and most
current address as indicated in the agency’s record is justified according to law.
16. I understand the court may, after considering a request, release identifying information from the court’s
adoption file.
17. I understand an action to nullify an adoption based on fraud m
ust be commenced within 3 years after entry of
the order of adoption or within 90 days of discovering the fraud, whichever is earlier.
18. I understand I have the following filing choices when I sign this Statement of Understanding and relinquishment
document:
A. I may choose to have the adoption agency file my relinquishment form immediately, or
B. I may choose to have the adoption agency hold the relinquishment form for up to 30 days so I can think
about my decision. I understand my child will not be placed for adoption during any holding period, or
C. I may agree with the adoption agency to hold the relinquishment form for more than 30 days if my child
must be freed for adoption from any other parent(s). I understand my child will not be placed for adoption
during any holding period.
Put a check mark in front of the one statement that says what filing choice you want:
I want the relinquishment form filed immediately.
I want the relinquishment form held for days until .
I agree to have the relinquishment form held until my child has been freed for adoption from any other
parent(s).
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The date of my first interview was: _________________________________________
The date of my most recent interview was: ___________________________________
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The date my
services were provided:
___________________
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___________________________________________ _____________________________________
__________________________________ ___________________________________________________________
Page 5 of 6
AD 885 (3/14) Mother or a Biological/Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
(NAME OF STATE)
(NAME OF PARENT)
(NAME OF AGENCY)
(DATE)
(NAME OF CHILD)
(SIGNATURE OF PARENT)
19. Mark the boxes of the statements that apply to you.
A. I reside in California;
I am in California but reside in (Approved ICPC 100A is
attached); or
I reside outside of California and I am relinquishing the above-named child under California
Family Code Section 8700(d), which applies because I have physical custody of my child.
I have had at least two face-to-face interviews with a social worker from the adoption agency on two
different days. At the first interview, the adoption agency gave me sample copies of this Statement
of Understanding and the relinquishment document. The agency may accept my relinquishment at
the second or later interview.
B. I reside outside of California and I do not have physical custody of the above-named child. I am
relinquishing the above named child under California Family Code Section 8700(c).
(If the non-custodial parent is relinquishing the child under California Family Code Section 8700(c)
and resides outside of California, the agency is only required to attempt to provide services per
Calif
ornia Code of Regulations, Title 22 Section 35129(b).)
I have received services from the adoption agency (example - telephone interview).
I have not received services from the adoption agency.
20. I have carefully thought about the reasons for keeping or giving up my child for adoption. I have discussed the
adoption plan of my child with the adoption agency, and I have decided giving my child to the agency for
adoption is in the best interest of my child. I have read and understand the Statement of Understanding and the
relinquishment document. I do not need any more help or time to make my decision. I have decided to
relinquish my child permanently to for adoption.
I have named the prospective adoptive parent(s).
I have not named the prospective adoptive parent(s).
I, mother/father of ,
understand and agree to the statements I have initialed above and I am signing this freely and willingly.
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________________
__________________________________ ___________________________________________________
__________________________________ by _________________________________________________
________________ ____________________________________ _______________________________________
________________ ____________________________________ _______________________________________
STATE OF ___________________________
COUNTY OF _________________________
__________________________ _________________________________________________________
_________________________________ ___________________________________________________
_________________________ ______________________________
Page 6 of 6
)
)
)
AD 885 (3/14) Mother or a Biological/Presumed Father of a Child Who Is Not Detained, a Juvenile Court
Dependent in Out-of-home Care, or the Ward of a Legal Guardian. (This form replaces AD 4338)
(DATE)
(DATE)
(DATE)
(DATE)
(WITNESS NAME)
(WITNESS NAME)
(WITNESS SIGNATURE)
(WITNESS SIGNATURE)
(NAME OF AUTHORIZED OFFICIAL)
(TITLE)
(NAME OF AGENCY)
(NAME OF RELINQUISHING PARENT)
SIGNATURE OF AUTHORIZED OFFICIAL
(NAME OF STATE)
(SIGNATURE OF AUTHORIZED OFFICIAL)
(NAME AND TITLE)
(NAME OF AGENCY)
(RELINQUISHING PARENT’S NAME)
(RELINQUISHING PARENT’S NAME)
Complete SECTION A if signed in California
SECTION A:
I, , an authorized official of
, accept this Statement of
Understanding of
The foregoing Statement of Understanding was signed on:
in the presence of:
Complete SECTION B if signed out of California (under California Family Code Section 8700(d))
SECTION B:
On before me, ,
of the , an
organization licensed or otherwise approved to provide adoption ser
vices under the laws of
, personally appeared , personally known to me (or
proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument
and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on
the instrument the person, or the entity upon behalf of which the person acted, executed the instrument.
Complete SECTION C if signed out of California (under California Family Code Section 8700(c))
SECTION C:
***COMPLETED BY NOTARY PUBLIC***
When the form is NOT BEING signed in the presence of an agency representative
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
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STATEMENT OF UNDERSTANDING AGENCY ADOPTIONS PROGRAM (California)

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Completed 7 April 2022

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