Withdrawal of Parental Consent to Adoption



On ___________ (Date), I, _____________________________, the ______________ (Father/Mother) of ____________________________, a ___________ (Male/Female) child born on _____________ (Date), consented to ________ (His/Her) adoption by ____________________________________ and _____________________________(Adoptive Parents).

I declare my intention to revoke my consent to said adoption agreement on the grounds that the following changes in my circumstances establish it to be in the best interest of ___________________________ (Child) to remain in my care and custody: _____________________________________________________ _____________________________________________________.

Therefore, I do hereby revoke my consent to the adoption agreement and declare said adoption agreement to be void and of no further effect.

In witness whereof, I have signed this instrument at ____________________________ (Place of Execution).

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Signature Date

This document was signed in the presence of the following:

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Signature Date

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Signature Date