THE STATE OF NEW HAMPSHIRE
Court Name: Case Name: Case Number:
DEPARTMENT OF HEALTH AND HUMAN SERVICES OR AGENCY SURRENDER OF PARENTAL RIGHTS
(RSA 170-B:5 through 170-B:12) 1. Name of agency surrendering rights Executive head or authorized representative Telephone Mailing Address 2. 3. Name of Child Date of birth Name of birth mother Date of birth mother's surrender or termination of parental rights (TPR) Place of surrender or TPR 4. Name of birth father Date of birth father's surrender or termination of parental rights (TPR) Place of surrender or TPR Case number Case number Place of birth Email address
Please read carefully the information below before signing this document.
By completing this surrender of parental rights, I understand that my department or agency will continue to have a legal relationship with the child, giving the department or agency responsibility for oversight of the support, medical, and other care of the minor child until a final decree of adoption has been issued. I understand that temporary care, custody and control of the child will be transferred to the adoptive parents during this interlocutory period. By signing this document below, I declare: h that I represent the department or agency having care, custody and control of the child; h that all the information on this surrender form is true; h that I have read and understand the content of this document; and h that I wish this surrender of parental rights to take effect.
Date Signature of Executive Head or Authorized Representative
State of This instrument was acknowledged before me on My Commission Expires
, County of by
Signature of Notarial Officer / Title
Affix Seal, if any
This surrender of parental rights is:
NHJB-2081-FP (10/01/2006) (formerly AOC-082SA-003)
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