Free Adoption Surrender - Massachusetts

The Commonwealth of Massachusetts The Trial Court Probate and Family Court Department
Division Docket No:

SURRENDER FORM
I, as the
(relationship)

of
(child's name)

age
(age of child) (place of birth)

, as the
(male - female)

sex born in

, on

(date of birth) (name of child)

do hereby voluntarily and unconditionally surrender to the care and custody of

(name of agency or person receiving custody)

for the purpose of adoption or such other disposition as may be made by a court of competent jurisdiction. I waive notice of any legal proceeding affecting the custody, guardianship, adoption or other disposition of

(name of child)

I UNDERSTAND THAT THIS SURRENDER IS FINAL AND CANNOT BE REVOKED.

(signature of person giving consent)

On this
(day)

day of
(month)

20

(year)

before me personally came and appeared and in my presence duly executed the foregoing instrument, and he/she acknowledged to me that he/she executed the same as his/her free act and deed, fully cognizant of its irrevocability. Date
Notary Public

State of County of Signed by as his/her freely executed

consent in the presence of each of us, and of each other, who thereafter have hereunto signed our names as witnesses
(signature of witness 1) (signature of witness 2)

(address of witness 1)

(address of witness 2)

CJ-P 85 (11/93)

c.f.g.