O.C.G.A. § 19-8-26 — GA Code / Title 19 / Chapter 8 / Section 19-8-26
Georgia Code Title 19. Domestic Relations § 19-8-26
Status: in_force

(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 NOTICE TO PARENT OR GUARDIAN: This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 5, you have the right to revoke this surrender within four days from the date you sign it. ____________________ STATE OF GEORGIA COUNTY OF _________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows: 1. I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights. 2. I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name of child-placing agency, out-of-state licensed 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 ______________________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child. Furthermore, I hereby agree that the ______________________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) may seek for the child a legal adoption by such individual or individuals as may be chosen by the ______________________________ (name of child-placing agency, out-of-state licensed 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. 3. 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 its investigation. 4. I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized. 5. I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time. 6. I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights. 7. Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily. This __________ day of __________, _____. _____________________________________________________ (Parent or guardian) ______________________________ Adult witness Sworn to and subscribed before me this __________ day of _______________, _____. ______________________________ Notary Public (SEAL) My commission expires: _______________.”

(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

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 5, you have the right to revoke this surrender within four days from the date you sign it.

____________________

STATE OF GEORGIA

COUNTY OF _________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.

2.

I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name of child-placing agency, out-of-state licensed 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 ______________________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child. Furthermore, I hereby agree that the ______________________________ (name of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) may seek for the child a legal adoption by such individual or individuals as may be chosen by the ______________________________ (name of child-placing agency, out-of-state licensed 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.

3.

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 its investigation.

4.

I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.

5.

I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency, out-of-state licensed agency, or Department of Human Services, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.

6.

I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.

7.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.

This __________ day of __________, _____.

_____________________________________________________

(Parent or guardian)

______________________________

Adult witness

Sworn to and subscribed

before me this __________

day of _______________, _____.

______________________________

Notary Public (SEAL)

My commission expires: _______________.”

(b) The notice to revoke a surrender of rights pursuant to subsection (a) of Code Section 19-8-9 shall conform substantially to the following form: “NOTICE TO REVOKE SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION I, the undersigned, executed a (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] as to the child identified in the surrender of rights document on ______________________________ (date). My relationship to the (child) (unborn child) [circle one] is that I am the (mother) (father) (alleged biological father) (guardian) [circle one]. (Complete this paragraph if the child has been born.) This notice to revoke my surrender of rights applies to the (female) (male) [circle one] child born ______________________________ (name of child) on ______________________________ (birthdate of child). I now wish to exercise my right to revoke my surrender of rights. I understand that for my revocation of surrender to be effective I must: A. Deliver the original of this document in person to the address designated in the surrender of rights document no later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document; OR B. Mail the original of this document by registered mail or by statutory overnight delivery to the address designated in the surrender of rights document no later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document. This __________ day of __________,_____. _____________________________________________________ (Parent, guardian, or alleged biological father) _____________________________________________________ (Printed name) ______________________________________________ Adult witness”

(b) The notice to revoke a surrender of rights pursuant to subsection (a) of Code Section 19-8-9 shall conform substantially to the following form:

“NOTICE TO REVOKE SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION

I, the undersigned, executed a (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] as to the child identified in the surrender of rights document on ______________________________ (date). My relationship to the (child) (unborn child) [circle one] is that I am the (mother) (father) (alleged biological father) (guardian) [circle one].

(Complete this paragraph if the child has been born.) This notice to revoke my surrender of rights applies to the (female) (male) [circle one] child born ______________________________ (name of child) on ______________________________ (birthdate of child).

I now wish to exercise my right to revoke my surrender of rights.

I understand that for my revocation of surrender to be effective I must:

A. Deliver the original of this document in person to the address designated in the surrender of rights document no later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document;

A. Deliver the original of this document in person to the address designated in the surrender of rights document no later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document;

OR

B. Mail the original of this document by registered mail or by statutory overnight delivery to the address designated in the surrender of rights document no later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document. This __________ day of __________,_____. _____________________________________________________ (Parent, guardian, or alleged biological father) _____________________________________________________ (Printed name) ______________________________________________ Adult witness”

B. Mail the original of this document by registered mail or by statutory overnight delivery to the address designated in the surrender of rights document no later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day of the revocation period specified in the surrender of rights document.

This __________ day of __________,_____.

_____________________________________________________

(Parent, guardian, or alleged biological father)

_____________________________________________________

(Printed name)

______________________________________________

Adult witness”

(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: This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 8, you have the right to revoke this surrender within four days from the date you sign it. ____________________ STATE OF GEORGIA COUNTY OF _________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, _________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows: 1. I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights. 2. I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name, surname not required, of each individual to whom surrender is made), PROVIDED that each such individual 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 that I sign this document. Furthermore, I promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by ______________________________ (name, surname not required, of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child. 3. It is also my wish, intent, and purpose that if each such individual identified in paragraph 2 is not named as petitioner in a petition for adoption within the 60 day period, other than for justifiable good cause, or, if said petition for adoption is filed within 60 days but the adoption proceeding is dismissed with prejudice or otherwise concluded without an order declaring the child to be the adopted child of each such individual, then I do hereby surrender my rights to the child as follows: Indicate your choice by signing ONE of the following statements (you may choose statement A, B, or C): A. ______________________________ (Signature) I wish the child returned to me, as provided by subsection (j) of Code Section 19-8-5 , and I expressly acknowledge that this provision applies only to the limited circumstance that the child is not adopted by the individual or individuals designated in this document 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 individual or individuals to adopt the child and that no other provision of this surrender impairs the validity, absolute finality, or totality of this surrender once the four-day revocation period has elapsed; OR B. ______________________________ (Signature) I surrender the child to __________________________________________________ (name of child-placing agency or out-of-state licensed agency), as provided in subsection (j) of Code Section 19-8-5 , for placement for adoption. I understand that if the child-placing agency or out-of-state licensed agency declines to accept the child for placement for adoption, this surrender will be in favor of the Department of Human Services for placement for adoption and ______________________________ (name of child-placing agency or out-of-state licensed 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; OR C. ______________________________ (Signature) I surrender the child to the Department of Human Services, as provided by subsection (j) of Code Section 19-8-5 , for placement for adoption; and the Department of Human Services may petition the superior court for custody of the child in accordance with the terms of this surrender. 4. I hereby agree that the child is to be adopted by each individual named in paragraph 2 or by any other individual as may be chosen by ______________________________ (name of child-placing agency or out-of-state licensed 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. 5. 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 individual named in paragraph 2 to adopt the child concerning the circumstances of placement of the child for adoption. 6. 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 its investigation. 7. I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized. 8. I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of each individual to whom surrender is made or his or her agent) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time. 9. I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights. 10. Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily. This __________ day of __________, _____. _____________________________________________________ (Parent or guardian) ______________________________ Adult witness Sworn to and subscribed before me this __________ day of _______________, _____. ______________________________ Notary Public (SEAL) My commission expires: _______________.”

(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:

This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 8, you have the right to revoke this surrender within four days from the date you sign it.

____________________

STATE OF GEORGIA

COUNTY OF _________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, _________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.

2.

I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name, surname not required, of each individual to whom surrender is made), PROVIDED that each such individual 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 that I sign this document. Furthermore, I promise not to interfere in the management of the child in any respect whatever; and, in consideration of the benefits guaranteed by ______________________________ (name, surname not required, of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.

3.

It is also my wish, intent, and purpose that if each such individual identified in paragraph 2 is not named as petitioner in a petition for adoption within the 60 day period, other than for justifiable good cause, or, if said petition for adoption is filed within 60 days but the adoption proceeding is dismissed with prejudice or otherwise concluded without an order declaring the child to be the adopted child of each such individual, then I do hereby surrender my rights to the child as follows:

Indicate your choice by signing ONE of the following statements (you may choose statement A, B, or C):

A. ______________________________ (Signature) I wish the child returned to me, as provided by subsection (j) of Code Section 19-8-5 , and I expressly acknowledge that this provision applies only to the limited circumstance that the child is not adopted by the individual or individuals designated in this document 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 individual or individuals to adopt the child and that no other provision of this surrender impairs the validity, absolute finality, or totality of this surrender once the four-day revocation period has elapsed;

A. ______________________________ (Signature) I wish the child returned to me, as provided by subsection (j) of Code Section 19-8-5 , and I expressly acknowledge that this provision applies only to the limited circumstance that the child is not adopted by the individual or individuals designated in this document 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 individual or individuals to adopt the child and that no other provision of this surrender impairs the validity, absolute finality, or totality of this surrender once the four-day revocation period has elapsed;

OR

B. ______________________________ (Signature) I surrender the child to __________________________________________________ (name of child-placing agency or out-of-state licensed agency), as provided in subsection (j) of Code Section 19-8-5 , for placement for adoption. I understand that if the child-placing agency or out-of-state licensed agency declines to accept the child for placement for adoption, this surrender will be in favor of the Department of Human Services for placement for adoption and ______________________________ (name of child-placing agency or out-of-state licensed 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;

B. ______________________________ (Signature) I surrender the child to __________________________________________________ (name of child-placing agency or out-of-state licensed agency), as provided in subsection (j) of Code Section 19-8-5 , for placement for adoption. I understand that if the child-placing agency or out-of-state licensed agency declines to accept the child for placement for adoption, this surrender will be in favor of the Department of Human Services for placement for adoption and ______________________________ (name of child-placing agency or out-of-state licensed 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;

OR

C. ______________________________ (Signature) I surrender the child to the Department of Human Services, as provided by subsection (j) of Code Section 19-8-5 , for placement for adoption; and the Department of Human Services may petition the superior court for custody of the child in accordance with the terms of this surrender.

C. ______________________________ (Signature) I surrender the child to the Department of Human Services, as provided by subsection (j) of Code Section 19-8-5 , for placement for adoption; and the Department of Human Services may petition the superior court for custody of the child in accordance with the terms of this surrender.

4.

I hereby agree that the child is to be adopted by each individual named in paragraph 2 or by any other individual as may be chosen by ______________________________ (name of child-placing agency or out-of-state licensed 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.

5.

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 individual named in paragraph 2 to adopt the child concerning the circumstances of placement of the child for adoption.

6.

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 its investigation.

7.

I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.

8.

I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of each individual to whom surrender is made or his or her agent) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.

9.

I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.

10.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.

This __________ day of __________, _____.

_____________________________________________________

(Parent or guardian)

______________________________

Adult 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 a 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 NOTICE TO ALLEGED BIOLOGICAL FATHER: This is an important legal document and by signing it you are surrendering all of your rights to the child identified in this document. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 4, you have the right to revoke this surrender within four days from the date you sign it. ____________________ STATE OF GEORGIA COUNTY OF _________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows: 1. I, the undersigned, alleged biological father of a (male) (female) [circle one] child, born ______________________________ (name of child) to ______________________________ (name of legal mother) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], being mindful that the child should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my rights. I, the undersigned, do hereby surrender my rights to 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 rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all control over the child. 2. 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. 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 its investigation. 3. I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized. 4. I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency representative, out-of-state licensed agency representative, Department of Human Services representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time. 5. I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights. 6. Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily. This __________ day of __________, _____. _____________________________________________________ (Alleged biological father) ______________________________ Adult 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 a 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

NOTICE TO ALLEGED BIOLOGICAL FATHER:

This is an important legal document and by signing it you are surrendering all of your rights to the child identified in this document. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 4, you have the right to revoke this surrender within four days from the date you sign it.

____________________

STATE OF GEORGIA

COUNTY OF _________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, alleged biological father of a (male) (female) [circle one] child, born ______________________________ (name of child) to ______________________________ (name of legal mother) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], being mindful that the child should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my rights. I, the undersigned, do hereby surrender my rights to 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 rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all control over the child.

2.

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. 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 its investigation.

3.

I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.

4.

I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency representative, out-of-state licensed agency representative, Department of Human Services representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.

5.

I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.

6.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.

This __________ day of __________, _____.

_____________________________________________________

(Alleged biological father)

______________________________

Adult witness

Sworn to and subscribed

before me this __________

day of _______________, _____.

______________________________

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: This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this surrender within four days from the date you sign it. ____________________ STATE OF GEORGIA COUNTY OF _________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows: 1. I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights. 2. I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name of each individual 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 ______________________________ (name of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child. 3. I hereby agree that ______________________________ (name of each individual 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. 4. I understand that under Georgia law an agent may be appointed by the court 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 its investigation. 5. I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized. 6. I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of each individual to whom surrender is made or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time. 7. I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights. 8. Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily. This __________ day of __________, _____. _____________________________________________________ (Parent or guardian) ______________________________ Adult witness Sworn to and subscribed before me this __________ day of _______________, _____. ______________________________ 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:

This is an important legal document and by signing it, you are surrendering all of your rights to the child identified in this document, so as to place the child for adoption. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this surrender within four days from the date you sign it.

____________________

STATE OF GEORGIA

COUNTY OF _________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent or guardian) who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one] child, born ______________________________ (name of child) on ______________________________ (birthdate of child) at ___:___ (A.M.) (P.M.) [circle one], should receive the benefits and advantages of a good home, to the end that (she) (he) [circle one] may be fitted for the requirements of life, consent to this surrender of my parental rights.

2.

I, the undersigned, ______________________________ (relationship to child) of the aforesaid child, do hereby surrender my rights to the child to ______________________________ (name of each individual 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 ______________________________ (name of each individual to whom surrender is made) in providing for the child, I do relinquish all rights to the child named in this document, it being my wish, intent, and purpose to relinquish absolutely all parental control over the child.

3.

I hereby agree that ______________________________ (name of each individual 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.

4.

I understand that under Georgia law an agent may be appointed by the court 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 its investigation.

5.

I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.

6.

I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand I may only revoke this surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of each individual to whom surrender is made or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.

7.

I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.

8.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.

This __________ day of __________, _____.

_____________________________________________________

(Parent or guardian)

______________________________

Adult witness

Sworn to and subscribed

before me this __________

day of _______________, _____.

______________________________

Notary public (SEAL)

My commission expires: _______________.”

(f) The pre-birth surrender of rights by a biological father who is not a 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: This is an important legal document and by signing it, you are surrendering any and all of your rights to the child identified in this document, so as to place the child 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. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this pre-birth surrender within four days from the date you sign it. ____________________ STATE OF GEORGIA COUNTY OF _________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows: 1. I, the undersigned, understand that I have been named by ______________________________, the biological 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 biological mother wishes to place this child for adoption. 2. 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. 3. 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 individual chosen by the child's legal mother or by any public or private agency that places children 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 four-day right of revocation) and, further, that by executing this document I am electing instead to surrender my rights before the child's birth. 4. I understand that signing this document does not fully and finally terminate my rights and responsibilities until an order from a court of competent jurisdiction terminating my rights or a final order of adoption is entered. I understand that if the child is not adopted after I sign this document, 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. 5. I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized. 6. I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand that I may only revoke this pre-birth surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency representative, out-of-state licensed agency representative, Department of Human Services representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this pre-birth surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time. 7. If prior to my signing this pre-birth surrender I have registered on Georgia's putative father registry then, if I do not revoke this surrender within the time permitted, I waive the notice I would be entitled to receive pursuant to Code Section 19-8-12 of the Official Code of Georgia Annotated because of my registration on the putative father registry. 8. I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights. 9. Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily. This __________ day of __________, _____. _____________________________________________________ (Alleged biological father) ______________________________ Adult witness Sworn to and subscribed before me this __________ day of _______________, _____. ______________________________ Notary public (SEAL) My commission expires: _______________.”

(f) The pre-birth surrender of rights by a biological father who is not a 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:

This is an important legal document and by signing it, you are surrendering any and all of your rights to the child identified in this document, so as to place the child 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. Understand that you are signing this document under oath and that if you knowingly and willfully make a false statement in this document you will be guilty of the crime of false swearing. As explained below in paragraph 6, you have the right to revoke this pre-birth surrender within four days from the date you sign it.

____________________

STATE OF GEORGIA

COUNTY OF _________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of alleged biological father) who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, understand that I have been named by ______________________________, the biological 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 biological mother wishes to place this child for adoption.

2.

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.

3.

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 individual chosen by the child's legal mother or by any public or private agency that places children 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 four-day right of revocation) and, further, that by executing this document I am electing instead to surrender my rights before the child's birth.

4.

I understand that signing this document does not fully and finally terminate my rights and responsibilities until an order from a court of competent jurisdiction terminating my rights or a final order of adoption is entered. I understand that if the child is not adopted after I sign this document, 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.

5.

I understand that I will receive a copy of this document after the witness and I have signed it and it has been notarized.

6.

I understand that under Georgia law I have the unconditional right to a four-day revocation period. I understand that I may only revoke this pre-birth surrender by giving written notice, delivered in person or mailed by registered mail or statutory overnight delivery, to ______________________________ (name and address of child-placing agency representative, out-of-state licensed agency representative, Department of Human Services representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing this document. I understand that certified mail cannot be used for mail delivery of the notice to revoke this pre-birth surrender. I understand that the four days will be counted consecutively beginning with the day immediately following the date I sign this document; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which this surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday. I understand that, if I deliver the notice to revoke this surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that I CANNOT revoke this surrender after that time.

7.

If prior to my signing this pre-birth surrender I have registered on Georgia's putative father registry then, if I do not revoke this surrender within the time permitted, I waive the notice I would be entitled to receive pursuant to Code Section 19-8-12 of the Official Code of Georgia Annotated because of my registration on the putative father registry.

8.

I understand that if I am not a resident of this state that I am agreeing to be subject to the jurisdiction of the courts of Georgia for any action filed in connection with the adoption of the child. I agree to be bound by a decree of adoption rendered as a result of this surrender of my parental rights.

9.

Furthermore, I hereby certify that I have not been subjected to any duress or undue pressure in the execution of this document and I am signing it freely and voluntarily.

This __________ day of __________, _____.

_____________________________________________________

(Alleged biological father)

______________________________

Adult witness

Sworn to and subscribed

before me 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 STATE OF GEORGIA COUNTY OF ______________________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent, guardian, or alleged biological father) who, after having been sworn, deposes and says as follows: (A) That I have read the accompanying (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] relating to the child born ______________________________ (name of child), a (male) (female) [circle one] on ______________________________ (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 ______________________________ (name and address of child-placing agency or its representative, out-of-state licensed agency or its representative, Department of Human Services or its representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing the surrender and that after such four-day revocation period I shall have no right to revoke the surrender. I understand that certified mail cannot be used for mail delivery of the notice to revoke the surrender of my rights. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that the four days will be counted consecutively beginning with the day immediately following the date I signed the surrender; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which the surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday; (D) That I have read the accompanying surrender of rights and received a copy thereof; (E) That any and all questions regarding the effect of such surrender and its provisions have been satisfactorily explained to me; (F) That I have been given an opportunity to consult with an attorney of my choice before signing the surrender of my rights; and (G) That the surrender of my rights has been knowingly, intentionally, freely, and voluntarily made by me. This __________ day of __________, _____. __________________________________________________ (Parent, guardian, or alleged biological father) ______________________________ Adult witness Sworn to and subscribed before me 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

STATE OF GEORGIA

COUNTY OF ______________________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent, guardian, or alleged biological father) who, after having been sworn, deposes and says as follows:

(A) That I have read the accompanying (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] relating to the child born ______________________________ (name of child), a (male) (female) [circle one] on ______________________________ (birthdate of child);

(A) That I have read the accompanying (PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) (SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION) [circle one] relating to the child born ______________________________ (name of child), a (male) (female) [circle one] on ______________________________ (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;

(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 ______________________________ (name and address of child-placing agency or its representative, out-of-state licensed agency or its representative, Department of Human Services or its representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing the surrender and that after such four-day revocation period I shall have no right to revoke the surrender. I understand that certified mail cannot be used for mail delivery of the notice to revoke the surrender of my rights. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that the four days will be counted consecutively beginning with the day immediately following the date I signed the surrender; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which the surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday;

(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 ______________________________ (name and address of child-placing agency or its representative, out-of-state licensed agency or its representative, Department of Human Services or its representative, individual to whom surrender is made or his or her agent, or petitioner's representative, as applicable) within four days from the date of signing the surrender and that after such four-day revocation period I shall have no right to revoke the surrender. I understand that certified mail cannot be used for mail delivery of the notice to revoke the surrender of my rights. I understand that, if I deliver the notice to revoke my surrender in person, it must be delivered to ______________________________ (name and address) not later than 5:00 P.M. eastern standard time or eastern daylight time, whichever is applicable, on the fourth day; provided, however, that if I mail the notice by registered mail or have it delivered by statutory overnight delivery, I must address it to the address shown in the surrender document and submit it to the United States Postal Service or to the statutory overnight delivery carrier not later than 12:00 Midnight eastern standard time or eastern daylight time, whichever is applicable, on the fourth day. I understand that the four days will be counted consecutively beginning with the day immediately following the date I signed the surrender; provided, however, that, if the fourth day falls on a Saturday, Sunday, or legal holiday, then the last day on which the surrender may be revoked will be the next day that is not a Saturday, Sunday, or legal holiday;

(D) That I have read the accompanying surrender of rights and received a copy thereof;

(D) That I have read the accompanying surrender of rights and received a copy thereof;

(E) That any and all questions regarding the effect of such surrender and its provisions have been satisfactorily explained to me;

(E) That any and all questions regarding the effect of such surrender and its provisions have been satisfactorily explained to me;

(F) That I have been given an opportunity to consult with an attorney of my choice before signing the surrender of my rights; and

(F) That I have been given an opportunity to consult with an attorney of my choice before signing the surrender of my rights; and

(G) That the surrender of my rights has been knowingly, intentionally, freely, and voluntarily made by me. This __________ day of __________, _____. __________________________________________________ (Parent, guardian, or alleged biological father) ______________________________ Adult witness Sworn to and subscribed before me this __________ day of _______________, _____. ______________________________ Notary public (SEAL) My commission expires: _______________.”

(G) That the surrender of my rights has been knowingly, intentionally, freely, and voluntarily made by me.

This __________ day of __________, _____.

__________________________________________________

(Parent, guardian, or alleged biological father)

______________________________

Adult witness

Sworn to and subscribed

before me this __________

day of _______________, _____.

______________________________

Notary public (SEAL)

My commission expires: _______________.”

(h) The affidavit of a legal mother required by paragraph (1) of subsection (g) of Code Section 19-8-4 , 19-8-5 , 19-8-6 , or 19-8-7 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 at the time of conception and of the birth of the child; (E) The identity and last known address of her spouse or former spouse and whether any such spouse is the biological father of the child; (F) The identity, last known address, and relationship to the legal mother of the biological father of the child, provided that she shall have the right not to disclose the name and address of the biological father of the child should she so desire; (G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name and address of the temporary guardian and the probate court in which the petition for temporary guardianship was filed; (H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; (I) Whether or not the biological father of the child is or was in a branch of the United States armed forces and, if so, provide details as to his military service; (J) Whether or not the biological mother or any member of her family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; (K) Whether or not the biological father of the child or any member of his family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; and (L) 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 her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received; and (2) The affidavit shall conform substantially to the following form: “LEGAL MOTHER'S AFFIDAVIT NOTICE TO LEGAL MOTHER: This is an important legal document which deals with the child's right to have his or her biological father's rights properly determined. You have the right not to disclose the name and address of the biological father of the child. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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 legal mother of a (male) (female) [circle one] child born ____________________ (name of child) in the State of __________, County of ________ on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one]. That I am ________ years of age, having been born in the State of ________, County of ________ on ______________. That my social security number is ________________. That my marital status at the time of the conception of the 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 (was) (is) [circle one] _____________________________________; my spouse's 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 ____________________ (date); my spouse (is) (is not) [circle one] the biological father of said child. ( ) Divorced; the name of my former spouse is _______________________; we were married in the State of ________, County of ________ on ________; we last had sexual relations on ________________ (date); my former spouse's last known address is ______________; divorce granted in the State of __________, County of ________ on ______________; my former spouse (is) (is not) [circle one] the biological father of said child. ( ) Legally married; the name of my spouse (was) (is) [circle one] ______________; we were married in the State of ________, County of ________ on ________; and my spouse's last known address is______________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________; my spouse's last known address is ______________; our relationship began in the State of _______, County of _________ on ___________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Widowed; the name of my deceased spouse was _______________________; we were married in the State of ________, County of ________ on ________; my spouse died on ________ in the County of ________, State of _________. That my name and marital status at the time of the birth of the 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) [circle one] ________________________________________________________; my spouse's 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 ___________________(date); my spouse (is) (is not) [circle one] the biological father of said child. ( ) Divorced; the name of my former spouse is ______________; we were married in the State of __________, County of __________ on __________; we last had sexual relations on ____________________ (date); my spouse's last known address is ___________________________; divorce granted in the State of ________________, County of __________; my former spouse (is) (is not) [circle one] the biological father of said child. ( ) Legally married; the name of my spouse (was) (is) [circle one] ___________________; we were married in the State of __________, County of _____________ on____________; my spouse's last known address is _________________________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Married through common-law relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________________; my spouse's last known address is ____________________; our relationship began in the State of ______________, County of ______________ on ______________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Widowed; the name of my deceased spouse was _____________; we were married in the State of _________, County of _____________ on ______________; my spouse died on ______________ in the County of ______________, State of ______________; he (was) (was not) [circle one] the biological father of said child. That the name of the biological father of the 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 the 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) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so: (A) The name of my American Indian tribe is ______________. (B) The percentage of my American Indian blood is ______ percent. That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of the American Indian tribe is . (B) The percentage of my American Indian blood is _______percent. (C) My relatives with American Indian or Alaskan native blood are . (D) The name of the American Indian tribe is . (E) The name of each enrolled member is _______________________, and his or her corresponding registration or identification number is ____________________. That, to the best of my knowledge, the biological father or a member of his family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of his American Indian tribe is ______________. (B) The percentage of his American Indian blood is ______ percent. (C) His relatives with American Indian or Alaskan native blood are . (D) The name of each enrolled member is_____________________________________, and his or her corresponding registration or identification number is ________________________. That the date of birth of the biological father (is _____________, ____) (is not known to me) [circle one]. That the biological father (is) (is not) [circle one] 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) [circle one]. (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 the child, whether or not identified in this document (circle the appropriate 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; and (Has) (Has not) provided for my medical care during my pregnancy or hospitalization for the birth of the child. That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is ____________________, and the probate court in which the petition for temporary guardianship was filed is ____________________. That custody of the child has been awarded to _________________________________ (name and address of custodian) by order of the ______________________ Court of _______________ County, State of ____________, entered on ____________(date). 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 the child, and the 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. _____________________________________________ (Legal mother) Sworn to and subscribed before me this ________ day of __________, ____. ______________________________ Notary public (SEAL) My commission expires __________.”

(h) The affidavit of a legal mother required by paragraph (1) of subsection (g) of Code Section 19-8-4 , 19-8-5 , 19-8-6 , or 19-8-7 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 at the time of conception and of the birth of the child; (E) The identity and last known address of her spouse or former spouse and whether any such spouse is the biological father of the child; (F) The identity, last known address, and relationship to the legal mother of the biological father of the child, provided that she shall have the right not to disclose the name and address of the biological father of the child should she so desire; (G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name and address of the temporary guardian and the probate court in which the petition for temporary guardianship was filed; (H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; (I) Whether or not the biological father of the child is or was in a branch of the United States armed forces and, if so, provide details as to his military service; (J) Whether or not the biological mother or any member of her family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; (K) Whether or not the biological father of the child or any member of his family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; and (L) 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 her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received; and

(1) The affidavit shall set forth:

(A) Her name;

(A) Her name;

(B) Her relationship to the child;

(B) Her relationship to the child;

(C) Her age;

(C) Her age;

(D) Her marital status at the time of conception and of the birth of the child;

(D) Her marital status at the time of conception and of the birth of the child;

(E) The identity and last known address of her spouse or former spouse and whether any such spouse is the biological father of the child;

(E) The identity and last known address of her spouse or former spouse and whether any such spouse is the biological father of the child;

(F) The identity, last known address, and relationship to the legal mother of the biological father of the child, provided that she shall have the right not to disclose the name and address of the biological father of the child should she so desire;

(F) The identity, last known address, and relationship to the legal mother of the biological father of the child, provided that she shall have the right not to disclose the name and address of the biological father of the child should she so desire;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name and address of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name and address of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded;

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded;

(I) Whether or not the biological father of the child is or was in a branch of the United States armed forces and, if so, provide details as to his military service;

(I) Whether or not the biological father of the child is or was in a branch of the United States armed forces and, if so, provide details as to his military service;

(J) Whether or not the biological mother or any member of her family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native;

(J) Whether or not the biological mother or any member of her family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native;

(K) Whether or not the biological father of the child or any member of his family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; and

(K) Whether or not the biological father of the child or any member of his family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; and

(L) 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 her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received; and

(L) 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 her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received; and

(2) The affidavit shall conform substantially to the following form: “LEGAL MOTHER'S AFFIDAVIT NOTICE TO LEGAL MOTHER: This is an important legal document which deals with the child's right to have his or her biological father's rights properly determined. You have the right not to disclose the name and address of the biological father of the child. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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 legal mother of a (male) (female) [circle one] child born ____________________ (name of child) in the State of __________, County of ________ on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one]. That I am ________ years of age, having been born in the State of ________, County of ________ on ______________. That my social security number is ________________. That my marital status at the time of the conception of the 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 (was) (is) [circle one] _____________________________________; my spouse's 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 ____________________ (date); my spouse (is) (is not) [circle one] the biological father of said child. ( ) Divorced; the name of my former spouse is _______________________; we were married in the State of ________, County of ________ on ________; we last had sexual relations on ________________ (date); my former spouse's last known address is ______________; divorce granted in the State of __________, County of ________ on ______________; my former spouse (is) (is not) [circle one] the biological father of said child. ( ) Legally married; the name of my spouse (was) (is) [circle one] ______________; we were married in the State of ________, County of ________ on ________; and my spouse's last known address is______________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________; my spouse's last known address is ______________; our relationship began in the State of _______, County of _________ on ___________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Widowed; the name of my deceased spouse was _______________________; we were married in the State of ________, County of ________ on ________; my spouse died on ________ in the County of ________, State of _________. That my name and marital status at the time of the birth of the 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) [circle one] ________________________________________________________; my spouse's 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 ___________________(date); my spouse (is) (is not) [circle one] the biological father of said child. ( ) Divorced; the name of my former spouse is ______________; we were married in the State of __________, County of __________ on __________; we last had sexual relations on ____________________ (date); my spouse's last known address is ___________________________; divorce granted in the State of ________________, County of __________; my former spouse (is) (is not) [circle one] the biological father of said child. ( ) Legally married; the name of my spouse (was) (is) [circle one] ___________________; we were married in the State of __________, County of _____________ on____________; my spouse's last known address is _________________________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Married through common-law relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________________; my spouse's last known address is ____________________; our relationship began in the State of ______________, County of ______________ on ______________; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Widowed; the name of my deceased spouse was _____________; we were married in the State of _________, County of _____________ on ______________; my spouse died on ______________ in the County of ______________, State of ______________; he (was) (was not) [circle one] the biological father of said child. That the name of the biological father of the 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 the 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) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so: (A) The name of my American Indian tribe is ______________. (B) The percentage of my American Indian blood is ______ percent. That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of the American Indian tribe is . (B) The percentage of my American Indian blood is _______percent. (C) My relatives with American Indian or Alaskan native blood are . (D) The name of the American Indian tribe is . (E) The name of each enrolled member is _______________________, and his or her corresponding registration or identification number is ____________________. That, to the best of my knowledge, the biological father or a member of his family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of his American Indian tribe is ______________. (B) The percentage of his American Indian blood is ______ percent. (C) His relatives with American Indian or Alaskan native blood are . (D) The name of each enrolled member is_____________________________________, and his or her corresponding registration or identification number is ________________________. That the date of birth of the biological father (is _____________, ____) (is not known to me) [circle one]. That the biological father (is) (is not) [circle one] 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) [circle one]. (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 the child, whether or not identified in this document (circle the appropriate 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; and (Has) (Has not) provided for my medical care during my pregnancy or hospitalization for the birth of the child. That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is ____________________, and the probate court in which the petition for temporary guardianship was filed is ____________________. That custody of the child has been awarded to _________________________________ (name and address of custodian) by order of the ______________________ Court of _______________ County, State of ____________, entered on ____________(date). 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 the child, and the 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. _____________________________________________ (Legal mother) Sworn to and subscribed before me this ________ day of __________, ____. ______________________________ Notary public (SEAL) My commission expires __________.”

(2) The affidavit shall conform substantially to the following form:

“LEGAL MOTHER'S AFFIDAVIT

NOTICE TO LEGAL MOTHER:

This is an important legal document which deals with the child's right to have his or her biological father's rights properly determined. You have the right not to disclose the name and address of the biological father of the child. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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 legal mother of a (male) (female) [circle one] child born ____________________ (name of child) in the State of __________, County of ________ on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one].

That I am ________ years of age, having been born in the State of ________, County of ________ on ______________.

That my social security number is ________________.

That my marital status at the time of the conception of the 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 (was) (is) [circle one] _____________________________________; my spouse's 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 ____________________ (date); my spouse (is) (is not) [circle one] the biological father of said child.

( ) Divorced; the name of my former spouse is _______________________; we were married in the State of ________, County of ________ on ________; we last had sexual relations on ________________ (date); my former spouse's last known address is ______________; divorce granted in the State of __________, County of ________ on ______________; my former spouse (is) (is not) [circle one] the biological father of said child.

( ) Legally married; the name of my spouse (was) (is) [circle one] ______________; we were married in the State of ________, County of ________ on ________; and my spouse's last known address is______________; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________; my spouse's last known address is ______________; our relationship began in the State of _______, County of _________ on ___________; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Widowed; the name of my deceased spouse was _______________________; we were married in the State of ________, County of ________ on ________; my spouse died on ________ in the County of ________, State of _________.

That my name and marital status at the time of the birth of the 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) [circle one] ________________________________________________________; my spouse's 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 ___________________(date); my spouse (is) (is not) [circle one] the biological father of said child.

( ) Divorced; the name of my former spouse is ______________; we were married in the State of __________, County of __________ on __________; we last had sexual relations on ____________________ (date); my spouse's last known address is ___________________________; divorce granted in the State of ________________, County of __________; my former spouse (is) (is not) [circle one] the biological father of said child.

( ) Legally married; the name of my spouse (was) (is) [circle one] ___________________; we were married in the State of __________, County of _____________ on____________; my spouse's last known address is _________________________; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Married through common-law relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ___________________________; my spouse's last known address is ____________________; our relationship began in the State of ______________, County of ______________ on ______________; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Widowed; the name of my deceased spouse was _____________; we were married in the State of _________, County of _____________ on ______________; my spouse died on ______________ in the County of ______________, State of ______________; he (was) (was not) [circle one] the biological father of said child.

That the name of the biological father of the 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 the 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) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so:

(A) The name of my American Indian tribe is ______________.

(A) The name of my American Indian tribe is ______________.

(B) The percentage of my American Indian blood is ______ percent.

(B) The percentage of my American Indian blood is ______ percent.

That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so:

(A) The name of the American Indian tribe is .

(A) The name of the American Indian tribe is .

(B) The percentage of my American Indian blood is _______percent.

(B) The percentage of my American Indian blood is _______percent.

(C) My relatives with American Indian or Alaskan native blood are .

(C) My relatives with American Indian or Alaskan native blood are .

(D) The name of the American Indian tribe is .

(D) The name of the American Indian tribe is .

(E) The name of each enrolled member is _______________________, and his or her corresponding registration or identification number is ____________________.

(E) The name of each enrolled member is _______________________, and his or her corresponding registration or identification number is ____________________.

That, to the best of my knowledge, the biological father or a member of his family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so:

(A) The name of his American Indian tribe is ______________.

(A) The name of his American Indian tribe is ______________.

(B) The percentage of his American Indian blood is ______ percent.

(B) The percentage of his American Indian blood is ______ percent.

(C) His relatives with American Indian or Alaskan native blood are .

(C) His relatives with American Indian or Alaskan native blood are .

(D) The name of each enrolled member is_____________________________________, and his or her corresponding registration or identification number is ________________________.

(D) The name of each enrolled member is_____________________________________, and his or her corresponding registration or identification number is ________________________.

That the date of birth of the biological father (is _____________, ____) (is not known to me) [circle one].

That the biological father (is) (is not) [circle one] 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) [circle one].

(A) The branch of his service is (Army) (Navy) (Marine) (Air Force) (Coast Guard) [circle one].

(B) His rank is .

(B) His rank is .

(C) His duty station is . If applicable, please provide any additional available information regarding his military service. .

(C) His duty station is .

If applicable, please provide any additional available information regarding his military service.

.

That the biological father of the child, whether or not identified in this document (circle the appropriate 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; and

(Has) (Has not) provided for my medical care during my pregnancy or hospitalization for the birth of the child.

That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is ____________________, and the probate court in which the petition for temporary guardianship was filed is ____________________.

That custody of the child has been awarded to _________________________________ (name and address of custodian) by order of the ______________________ Court of _______________ County, State of ____________, entered on ____________(date).

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 the child, and the 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.

_____________________________________________

(Legal mother)

Sworn to and subscribed

before me this ________

day of __________, ____.

______________________________

Notary public (SEAL)

My commission expires __________.”

(i) The affidavit of an adoptive mother required by paragraph (2) of subsection (g) of Code Section 19-8-4 , 19-8-5 , 19-8-6 , or 19-8-7 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 or former spouse at the time the child was adopted and whether any such spouse also adopted the child or is the biological father of the child; (F) The circumstances surrounding her adoption of the 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; (G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name of the temporary guardian and the probate court in which the petition for temporary guardianship was filed; (H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; and (I) 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 the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she 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 ADOPTIVE MOTHER: This is an important legal document which deals with the adopted child's right to have his or her legal father's rights properly determined. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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) [circle one] child born ____________________ (name of child) in the State of __________, County of __________ on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one]. That I am ________ years of age, having been born in the State of ________, County of __________ on ______________. That my social security number is ________________. 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 (was) (is) [circle one] ______________; my spouse's 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 ______________ (date); my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Divorced; the name of my former spouse is______________; we were married in the State of ________, County of __________ on ______________; we last had sexual relations on ______________ (date); my former spouse's last known address is ______________; divorce granted in the State of ________, County of __________ on ______________; my former spouse (did) (did not) [circle one] also adopt said child; my former spouse (is) (is not) [circle one] the biological father of said child. ( ) Legally married; the name of my spouse (was) (is) [circle one] ______________; we were married in the State of ________, County of __________ on ______________; my spouse's last known address is______________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ______________; my spouse's last known address is______________; our relationship began in the State of ______________, County of _____________ on_____________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child. ( ) Widowed; the name of my deceased spouse was__________; we were married in the State of __________, County of __________ on__________; my spouse died on __________ in the County of __________, State of __________; he (did) (did not) [circle one] also adopt said child; he (was) (was not) [circle one] the biological father of said child. That I adopted the child in the State of ________, County of _______________. That the final order of adoption was entered on . That there (was) (was not) [circle one] an adoption agency involved in the placement of the child with me for adoption; and if so its name was ___________________, and its address is . That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is: __________________________, and the probate court in which the petition for temporary guardianship was filed is . That custody of the child has been awarded to ____________________ (name and address of custodian) by order of the ______________ Court of _______________ County, State of _______________, entered on _______________(date). That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the 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 (SEAL) My commission expires: __________.”

(i) The affidavit of an adoptive mother required by paragraph (2) of subsection (g) of Code Section 19-8-4 , 19-8-5 , 19-8-6 , or 19-8-7 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 or former spouse at the time the child was adopted and whether any such spouse also adopted the child or is the biological father of the child; (F) The circumstances surrounding her adoption of the 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; (G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name of the temporary guardian and the probate court in which the petition for temporary guardianship was filed; (H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; and (I) 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 the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received.

(1) The affidavit shall set forth:

(A) Her name;

(A) Her name;

(B) Her relationship to the child;

(B) Her relationship to the child;

(C) Her age;

(C) Her age;

(D) Her marital status;

(D) Her marital status;

(E) The name and last known address of any spouse or former spouse at the time the child was adopted and whether any such spouse also adopted the child or is the biological father of the child;

(E) The name and last known address of any spouse or former spouse at the time the child was adopted and whether any such spouse also adopted the child or is the biological father of the child;

(F) The circumstances surrounding her adoption of the 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;

(F) The circumstances surrounding her adoption of the 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;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; and

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; and

(I) 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 the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received.

(I) 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 the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received.

(2) The affidavit shall be in substantially the following form:

(2) The affidavit shall be in substantially the following form:

“ADOPTIVE MOTHER'S AFFIDAVIT

NOTICE TO ADOPTIVE MOTHER:

This is an important legal document which deals with the adopted child's right to have his or her legal father's rights properly determined. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. The information you provide will be held in strict confidence and will be used only in connection with the adoption of the 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) [circle one] child born ____________________ (name of child) in the State of __________, County of __________ on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one].

That I am ________ years of age, having been born in the State of ________, County of __________ on ______________.

That my social security number is ________________.

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 (was) (is) [circle one] ______________; my spouse's 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 ______________ (date); my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Divorced; the name of my former spouse is______________; we were married in the State of ________, County of __________ on ______________; we last had sexual relations on ______________ (date); my former spouse's last known address is ______________; divorce granted in the State of ________, County of __________ on ______________; my former spouse (did) (did not) [circle one] also adopt said child; my former spouse (is) (is not) [circle one] the biological father of said child.

( ) Legally married; the name of my spouse (was) (is) [circle one] ______________; we were married in the State of ________, County of __________ on ______________; my spouse's last known address is______________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Married through common-law marriage relationship prior to January 1, 1997; the name of my spouse (was) (is) [circle one] ______________; my spouse's last known address is______________; our relationship began in the State of ______________, County of _____________ on_____________; my spouse (did) (did not) [circle one] also adopt said child; my spouse (is) (is not) [circle one] the biological father of said child.

( ) Widowed; the name of my deceased spouse was__________; we were married in the State of __________, County of __________ on__________; my spouse died on __________ in the County of __________, State of __________; he (did) (did not) [circle one] also adopt said child; he (was) (was not) [circle one] the biological father of said child.

That I adopted the child in the State of ________, County of _______________.

That the final order of adoption was entered on .

That there (was) (was not) [circle one] an adoption agency involved in the placement of the child with me for adoption; and if so its name was ___________________, and its address is .

That I (have) (have not) [circle one] consented to the appointment of a temporary guardian for the child. If so, the name of the temporary guardian is: __________________________, and the probate court in which the petition for temporary guardianship was filed is .

That custody of the child has been awarded to ____________________ (name and address of custodian) by order of the ______________ Court of _______________ County, State of _______________, entered on _______________(date).

That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the 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 (SEAL)

My commission expires: __________.”

(j) The affidavit of a child-placing agency, out-of-state licensed agency, or department representative required by subsection (h) of Code Section 19-8-4 shall conform substantially to the following form: “AFFIDAVIT OF CHILD-PLACING AGENCY, OUT-OF-STATE LICENSED AGENCY, OR DEPARTMENT REPRESENTATIVE 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 I am ____________________ (position) of _______________________ (name of department, child-placing agency, or out-of-state licensed agency). That prior to the execution of the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION by __________________________, releasing and surrendering all of (his) (her) [circle one] rights in a (male) (female) [circle one] child born _________________ (name of child) on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION. _______________________________________________ (Representative) _______________________________________________ (Department or agency name) Sworn to and subscribed before me this ________ day of __________, ____. ________________________________________ Notary public (SEAL) My commission expires: __________.”

(j) The affidavit of a child-placing agency, out-of-state licensed agency, or department representative required by subsection (h) of Code Section 19-8-4 shall conform substantially to the following form:

“AFFIDAVIT OF CHILD-PLACING AGENCY, OUT-OF-STATE LICENSED AGENCY, OR DEPARTMENT REPRESENTATIVE

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 I am ____________________ (position) of _______________________ (name of department, child-placing agency, or out-of-state licensed agency).

That prior to the execution of the accompanying SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION by __________________________, releasing and surrendering all of (his) (her) [circle one] rights in a (male) (female) [circle one] child born _________________ (name of child) on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

_______________________________________________

(Representative)

_______________________________________________

(Department or agency name)

Sworn to and subscribed

before me this ________

day of __________, ____.

________________________________________

Notary public (SEAL)

My commission expires: __________.”

(k) The affidavit of a petitioner's representative or of the representative of the individual signing the surrender of rights 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 REPRESENTATIVE 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 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) [circle one] rights in a (male) (female) [circle one] child born _________________ (name of child) on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION. _______________________________________________ (Petitioner's representative or the representative of the individual signing the surrender) Sworn to and subscribed before me this ________ day of __________, ____. ______________________________ Notary public (SEAL) My commission expires: _________________.”

(k) The affidavit of a petitioner's representative or of the representative of the individual signing the surrender of rights 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 REPRESENTATIVE

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 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) [circle one] rights in a (male) (female) [circle one] child born _________________ (name of child) on ____________________ (birthdate of child) at ____:____ (A.M.) (P.M.) [circle one], I reviewed with and explained to such individual all of the provisions of the surrender of rights, 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 such individual, it is my opinion that such individual knowingly, intentionally, freely, and voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

_______________________________________________

(Petitioner's representative or the representative of the individual signing the surrender)

Sworn to and subscribed

before me this ________

day of __________, ____.

______________________________

Notary public (SEAL)

My commission expires: _________________.”

(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 STATE OF GEORGIA COUNTY OF ____________________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent) who, after having been sworn, deposes and says as follows: I, the undersigned, hereby consent that my spouse ____________________ (name of spouse) adopt my (son) (daughter) [circle one], ____________________ (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 for adoption. I also waive all other and further service and notice of any kind and nature in connection with the proceedings. This ______ day of ______________,____. ______________________________________________ (Parent) Sworn to and subscribed before me this ________ day of _________, ____. ______________________________ Notary public (SEAL) My commission expires: ___________.”

(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

STATE OF GEORGIA

COUNTY OF ____________________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of parent) who, after having been sworn, deposes and says as follows:

I, the undersigned, hereby consent that my spouse ____________________ (name of spouse) adopt my (son) (daughter) [circle one], ____________________ (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 for adoption. I also waive all other and further service and notice of any kind and nature in connection with the proceedings.

This ______ day of ______________,____.

______________________________________________

(Parent)

Sworn to and subscribed

before me this ________

day of _________, ____.

______________________________

Notary public (SEAL)

My commission expires: ___________.”

(m) The sworn statement executed by the biological mother identifying an alleged biological father of her unborn child authorized and required by subparagraph (e)(3)(E) of Code Section 19-8-4 , 19-8-5 , or 19-8-7 shall conform substantially to the following form: “NOTICE TO BIOLOGICAL MOTHER: This is an important legal document which will enable the individual you identify as the biological father of your unborn child to sign a pre-birth surrender of his rights so as to place your child for adoption. Understand that you are signing this affidavit under oath and that the information you provide will be held in strict confidence and will be used only in connection with the adoption of your unborn child. STATE OF GEORGIA COUNTY OF ________ BIOLOGICAL MOTHER'S AFFIDAVIT IDENTIFYING BIOLOGICAL FATHER OF HER UNBORN CHILD 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 _____ years of age, having been born in the State of ______, County of _________ on ________________. That my social security number is ___________________. That I am currently pregnant with a (male) (female) (sex unknown) [circle one] child who is expected to be born on ____________________ (due date of child). That the name of any alleged biological father is ______________________________, and his last known address is . That I execute this affidavit so that any alleged biological father I have identified above can be asked to sign a pre-birth surrender of his rights to assist me in placing the child for adoption once the child is born. 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) Sworn to and subscribed before me this _________ day of _________,____. ______________________________ Notary public (SEAL) My commission expires: _____________.”

(m) The sworn statement executed by the biological mother identifying an alleged biological father of her unborn child authorized and required by subparagraph (e)(3)(E) of Code Section 19-8-4 , 19-8-5 , or 19-8-7 shall conform substantially to the following form:

“NOTICE TO BIOLOGICAL MOTHER:

This is an important legal document which will enable the individual you identify as the biological father of your unborn child to sign a pre-birth surrender of his rights so as to place your child for adoption. Understand that you are signing this affidavit under oath and that the information you provide will be held in strict confidence and will be used only in connection with the adoption of your unborn child.

STATE OF GEORGIA

COUNTY OF ________

BIOLOGICAL MOTHER'S AFFIDAVIT IDENTIFYING BIOLOGICAL FATHER OF HER UNBORN CHILD

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 _____ years of age, having been born in the State of ______, County of _________ on ________________.

That my social security number is ___________________.

That I am currently pregnant with a (male) (female) (sex unknown) [circle one] child who is expected to be born on ____________________ (due date of child).

That the name of any alleged biological father is ______________________________, and his last known address is .

That I execute this affidavit so that any alleged biological father I have identified above can be asked to sign a pre-birth surrender of his rights to assist me in placing the child for adoption once the child is born.

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)

Sworn to and subscribed

before me this _________

day of _________,____.

______________________________

Notary public (SEAL)

My commission expires: _____________.”

(n) The affidavit regarding Native American heritage and military service authorized and required by subsection (k) of Code Sections 19-8-4 , 19-8-6 , and 19-8-7 and subsection (o) of Code Section 19-8-5 shall conform substantially to the following form: “NOTICE TO BIOLOGICAL OR LEGAL FATHER: This is an important legal document. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing. _______________ AFFIDAVIT REGARDING NATIVE AMERICAN HERITAGE AND MILITARY SERVICE STATE OF GEORGIA COUNTY OF ___________ Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of affiant) who, after having been sworn, deposes and says as follows: 1. That my name is . 2. That I am the (biological) (legal) [circle one] father of a (male) (female) (sex unknown) [circle one] child (born) (yet to be born) [circle one] in the State of ______________, County of ______________ on ______________. 3. That I am _______ years of age, having been born in the State of ___________, County of _____________ on ____________________. 4. That my social security number is ______________________________. 5. That, to the best of my knowledge, I (am) (am not) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so: (A) The name of my American Indian tribe is . (B) My registration or identification number is . (C) The percentage of my American Indian blood is ___________ percent. 6. That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of the American Indian tribe is . (B) The percentage of my American Indian blood is ___________ percent. (C) My relatives with American Indian or Alaskan native blood are . (D) The name of the American Indian tribe is . (E) The name of each enrolled member is ______________________________, and his or her corresponding registration or identification number is . 7. That I (am) (am not) [circle one] on active duty in a branch of the United States armed forces. If so: (A) The branch of my service is (Army) (Navy) (Marine) (Air Force) (Coast Guard) [circle one]. (B) My rank is . (C) My duty station is . (D) Additional information regarding my military service is . 8. That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the birth of the child and the child's placement for adoption: . 9. 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 or legal father) Sworn to and subscribed before me this ________ day of _________, ____. _________________________________ Notary public (SEAL) My commission expires: _____________.”

(n) The affidavit regarding Native American heritage and military service authorized and required by subsection (k) of Code Sections 19-8-4 , 19-8-6 , and 19-8-7 and subsection (o) of Code Section 19-8-5 shall conform substantially to the following form:

“NOTICE TO BIOLOGICAL OR LEGAL FATHER:

This is an important legal document. Understand that you are providing this affidavit under oath and that if you knowingly and willfully make a false statement in this affidavit you will be guilty of the crime of false swearing.

_______________

AFFIDAVIT REGARDING NATIVE AMERICAN HERITAGE AND MILITARY SERVICE

STATE OF GEORGIA

COUNTY OF ___________

Personally appeared before me, the undersigned officer duly authorized to administer oaths, ______________________________ (name of affiant) who, after having been sworn, deposes and says as follows:

1. That my name is .

1. That my name is .

2. That I am the (biological) (legal) [circle one] father of a (male) (female) (sex unknown) [circle one] child (born) (yet to be born) [circle one] in the State of ______________, County of ______________ on ______________.

2. That I am the (biological) (legal) [circle one] father of a (male) (female) (sex unknown) [circle one] child (born) (yet to be born) [circle one] in the State of ______________, County of ______________ on ______________.

3. That I am _______ years of age, having been born in the State of ___________, County of _____________ on ____________________.

3. That I am _______ years of age, having been born in the State of ___________, County of _____________ on ____________________.

4. That my social security number is ______________________________.

4. That my social security number is ______________________________.

5. That, to the best of my knowledge, I (am) (am not) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so: (A) The name of my American Indian tribe is . (B) My registration or identification number is . (C) The percentage of my American Indian blood is ___________ percent.

5. That, to the best of my knowledge, I (am) (am not) [circle one] an enrolled member of a federally recognized American Indian tribe, (am) (am not) [circle one] a resident of an American Indian reservation, or (am) (am not) [circle one] an Alaskan native. If so:

(A) The name of my American Indian tribe is .

(A) The name of my American Indian tribe is .

(B) My registration or identification number is .

(B) My registration or identification number is .

(C) The percentage of my American Indian blood is ___________ percent.

(C) The percentage of my American Indian blood is ___________ percent.

6. That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so: (A) The name of the American Indian tribe is . (B) The percentage of my American Indian blood is ___________ percent. (C) My relatives with American Indian or Alaskan native blood are . (D) The name of the American Indian tribe is . (E) The name of each enrolled member is ______________________________, and his or her corresponding registration or identification number is .

6. That, to the best of my knowledge, a member of my family (is or was) (is not or was not) [circle one] an enrolled member of a federally recognized American Indian tribe, (is or was) (is not or was not) [circle one] a resident of an American Indian reservation, or (is or was) (is not or was not) [circle one] an Alaskan native. If so:

(A) The name of the American Indian tribe is .

(A) The name of the American Indian tribe is .

(B) The percentage of my American Indian blood is ___________ percent.

(B) The percentage of my American Indian blood is ___________ percent.

(C) My relatives with American Indian or Alaskan native blood are .

(C) My relatives with American Indian or Alaskan native blood are .

(D) The name of the American Indian tribe is .

(D) The name of the American Indian tribe is .

(E) The name of each enrolled member is ______________________________, and his or her corresponding registration or identification number is .

(E) The name of each enrolled member is ______________________________, and his or her corresponding registration or identification number is .

7. That I (am) (am not) [circle one] on active duty in a branch of the United States armed forces. If so: (A) The branch of my service is (Army) (Navy) (Marine) (Air Force) (Coast Guard) [circle one]. (B) My rank is . (C) My duty station is . (D) Additional information regarding my military service is .

7. That I (am) (am not) [circle one] on active duty in a branch of the United States armed forces. If so:

(A) The branch of my service is (Army) (Navy) (Marine) (Air Force) (Coast Guard) [circle one].

(A) The branch of my service is (Army) (Navy) (Marine) (Air Force) (Coast Guard) [circle one].

(B) My rank is .

(B) My rank is .

(C) My duty station is .

(C) My duty station is .

(D) Additional information regarding my military service is .

(D) Additional information regarding my military service is .

8. That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the birth of the child and the child's placement for adoption: .

8. That I have received or been promised the following financial assistance, either directly or indirectly, from whatever source, in connection with the birth of the child and the child's placement for adoption: .

9. 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 or legal father) Sworn to and subscribed before me this ________ day of _________, ____. _________________________________ Notary public (SEAL) My commission expires: _____________.”

9. 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 or legal father)

Sworn to and subscribed

before me this ________

day of _________, ____.

_________________________________

Notary public (SEAL)

My commission expires: _____________.”