Bill Text: GA HB1212 | 2011-2012 | Regular Session | Introduced
Bill Title: Adoption; withdrawing a surrender of parental rights; change period
Spectrum: Slight Partisan Bill (Republican 4-2)
Status: (Introduced - Dead) 2012-03-07 - House Second Readers [HB1212 Detail]
Download: Georgia-2011-HB1212-Introduced.html
12 LC
21 1689
House
Bill 1212
By:
Representatives Johnson of the
37th,
Cooper of the
41st,
Manning of the
32nd,
Oliver of the
83rd,
Dickson of the
6th,
and others
A
BILL TO BE ENTITLED
AN ACT
AN ACT
To
amend Article 1 of Chapter 8 of Title 19 of the Official Code of Georgia
Annotated, relating to general provisions relative to adoption, so as to change
the period for withdrawing a surrender of parental rights; to provide for
related matters, to repeal conflicting laws; and for other
purposes.
BE
IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:
SECTION
1.
Article
1 of Chapter 8 of Title 19 of the Official Code of Georgia Annotated, relating
to general provisions relative to adoption, is amended by revising Code Section
19-8-9, relating to surrender of parental rights where a legal mother puts up
for adoption a child she has previously adopted, withdrawal of surrender, and
expiration of rights, as follows:
"19-8-9.
(a)
In those cases where the legal mother of the child being placed for adoption has
herself previously adopted such child, said adoptive mother shall execute, in
lieu of the affidavit specified in subsection (g) of Code Section 19-8-4,
19-8-5, 19-8-6, or 19-8-7, an affidavit meeting the requirements of subsection
(i) of Code Section 19-8-26.
(b)
A person signing a surrender pursuant to Code Section 19-8-4, 19-8-5, 19-8-6, or
19-8-7 shall have the right to withdraw the surrender by written notice
delivered in person or mailed by registered mail or statutory overnight delivery
within ten
days
24
hours after signing; and the surrender
document shall not be valid unless it so states. The
ten days
shall be counted consecutively beginning with the day immediately following the
date
24 hour period
shall begin at midnight of the day 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last day on which the surrender may be withdrawn shall be the next day that is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.
After ten
days
24
hours, a surrender may not be withdrawn.
The notice of withdrawal of surrender shall be delivered in person or mailed by
registered mail or statutory overnight delivery to the address designated in the
surrender document.
(c)
If a legal mother has voluntarily and in writing surrendered all of her parental
rights pursuant to the provisions of subsection (a) of Code Section 19-8-4,
19-8-5, 19-8-6, or 19-8-7 and has not withdrawn her surrender within the
ten-day
24
hour period after signing as permitted by
the provisions of subsection (b) of this Code section, she shall have no right
or authority to sign either a voluntary acknowledgment of legitimation pursuant
to the provisions of paragraph (2) of subsection (g) of Code Section 19-7-22 or
a voluntary acknowledgment of paternity pursuant to the provisions of Code
Section 19-7-46.1 regarding the same child."
SECTION
2.
Said
article is further amended by revising Code Section 19-9-26, relating to how
surrender of parental rights is executed, how and when surrender may be
withdrawn, and forms, as follows:
"19-8-26.
(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
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
24 hours from
the time 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 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
(insert name
of child-placing agency or Department of Human Services, 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 Services, 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 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.
Furthermore,
I understand that under Georgia law the Department of Human Services 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 Services, as
applicable) within
ten
days
24
hours from the
date
time
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;
24 hour period
shall begin at midnight of the day I sign the
surrender, 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
(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:
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
24
hours from the
date
time
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 that each such person 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 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 Services, 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
Services 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
Services 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 evaluator is required to conduct and
provide to the court a home study and make recommendations to the court
regarding the qualification of each person named above to adopt a child
concerning the circumstances of placement of my child for adoption. I hereby
agree to cooperate fully with such investigations.
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
24
hours from the
date
time
hereof; that the
ten days
shall be counted consecutively beginning with the day immediately following the
date hereof; provided, however, that 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;
24 hour period
shall begin at midnight of the day I sign the
surrender, 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)
(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
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
24
hours 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 Services
representative, person to whom surrender is made, or petitioner's
representative, as appropriate) within
ten
days
24
hours from the
date
time
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;
24 hour period
shall begin at midnight of the day I sign the
surrender, 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 ______________, ____.
(Alleged biological father)
__________________
Unofficial witness
Sworn to and subscribed
before me this _____
day of ______________, ____.
____________________________
Notary public (SEAL)
My commission expires ______________.
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:
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
24
hours from the
date
time
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 Services 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
24
hours from the
date
time
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;
24 hour period
shall begin at midnight of the day I sign the
surrender, 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
(Parent or guardian)
__________________
Unofficial witness
_____________
Notary public
(f)
The pre-birth surrender of rights by a biological father who is not the legal
father of the child pursuant to paragraph (3) of subsection (e) of Code Section
19-8-4, 19-8-5, or 19-8-7 shall conform substantially to the following
form:
PRE-BIRTH
SURRENDER OF RIGHTS
FINAL RELEASE FOR ADOPTION
NOTICE TO ALLEGED BIOLOGICAL FATHER
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 right, title, and claim to the child identified herein, so as to
facilitate the child's placement 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. You are to receive a copy of this document
and as explained below have the right to withdraw your pre-birth surrender
within ten
days
24
hours from the
date
time
you sign it.
______________________
I,
the undersigned, understand that I have been named by __________________, the
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 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 person
chosen by the child's mother or by any public or private child-placing agency
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
ten-day
24
hour right of withdrawal) and, further,
that by executing this document I am electing instead to surrender my rights
before the child's birth.
I
further understand that execution of this document does not fully and finally
terminate my responsibilities until a final order of adoption is entered. I
understand that if the child is not adopted, 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.
Furthermore,
I hereby certify that I have received a copy of this document and that I
understand that I may only withdraw this pre-birth surrender by giving written
notice, delivered in person or by statutory overnight delivery or registered
mail, return receipt requested, to _________________________ within
ten
days
24
hours from the
date
time
hereof; that the
ten days
shall be counted consecutively beginning with the day immediately following the
date hereof; that, 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;
24 hour period
shall begin at midnight of the day I sign the
surrender, and that it may NOT be
withdrawn thereafter.
If
prior to my signing this pre-birth surrender I have registered on Georgia's
putative father registry then if I do not withdraw this surrender within the
time permitted, I waive the notice I would be entitled to receive pursuant to
the provisions of Code Section 19-8-12 of the Official Code of Georgia Annotated
because of my registration on the putative father registry.
Furthermore,
I hereby certify that I have not been subjected to any duress or undue pressure
in the execution of this 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 on this _____ day of
_____,
__________.
__________________
Notary
Public
Seal
My
commission expires: ___________.
(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
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
24
hours from the
date
time
of the surrender and that after such
ten-day
24
hour 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
24 hour period
shall begin at midnight of the day I sign the
surrender;
(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
(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 _____________.
(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
(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
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
(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 ______________, ____.
_____________
(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"
(Parent)
__________________
Unofficial witness
_____________
Notary public"
SECTION
3.
All
laws and parts of laws in conflict with this Act are repealed.