La. Ch. Code art. 1122 — LA Code / Code childrens-code / Article 1122
Contents of surrender; form
Status: in_force

A. Every Act of Surrender shall contain the following information:

(1) The name, parish of domicile, age, and marital status of the surrendering parent.

(2) The name and last address, if known, of any other legal or natural parent of the child or a statement that the name or address is not known.

(3) The birth name, place, date of birth of the child, and a statement as to whether the child is an Indian child.

(4) The name and address of the person, agency, or representative to whom surrender is made.

(5) The court in which the surrender is to be filed as required by Article 1131.

B. The Act of Surrender shall also recite the following declarations:

(1) That the act is not being executed earlier than (a) the third day following the birth of the child if it is an agency adoption, or (b) the fifth day following the birth of a child if the adoption is a private adoption; or, when a father is surrendering earlier than the fifth day following the birth of the child, that (a) the adoption is an agency adoption, or (b) that the act is for private adoption and is being executed earlier than the fifth day following the birth of the child.

(2) That the parent has no mental incapacity and is under no interdiction.

(3) That the parent who is a minor is joined in the act of surrender by the parents or tutor or has written consent of the court, except in acts of surrender to an agency.

(4) That the parent has been informed and understands that upon its execution, the Act of Surrender is irrevocable, and that any rights as a parent of the child are permanently terminated by execution of the Act of Surrender unless it is nullified due to fraud or duress or is dissolved by a court of competent jurisdiction.

(5) That the parent freely and voluntarily surrenders custody of the child for the purpose of permanent placement and adoption.

(6) That the parent consents to an adoption which consent is final and irrevocable.

(7) That the parent waives notice and service of any subsequent adoption proceedings.

(8) That the parent has been informed of the provisions of the voluntary registration law, as provided for in Chapter 15 of Title XII, whereby contact can be established between the parent and the surrendered child upon the child's reaching majority if both the surrendering parent and the adopted person register and fulfill all registration requirements.

(9) That either a surrendering parent, the agency accepting the surrender, or the adoptive parents are domiciled in this state, or that the child is in the custody of the Department of Children and Family Services.

(10) That the parent has been informed and fully advised of the provisions of R.S. 14:125.2, and the penalties provided therein, by an attorney, other than the attorney, associate, or partner of the law firm representing the adoptive parent. This includes employees and shareholders of any firm, company, corporation, or limited liability partnership that may be representing the adoptive parents.

(11) In an adoption arranged by the Department of Children and Family Services, that the execution of the surrender is made without conditions of any kind. Failure to comply with any formal or informal agreement for post-adoption continuing contact shall not nullify the surrender nor constitute cause for its revocation.

(12) Whether a surrendering mother does or does not wish to be notified of the hearing of any opposition to the adoption filed pursuant to Article 1137.

(13) Whether a surrendering parent does or does not wish the future release of identifying information in the event of a medical necessity for which information is needed in order to treat the child.

(14) That the parent has been informed that the Statement of Family History will be given to the adoptive parents at the time of placement and made available, upon request, to the adopted person at the age of eighteen years or older.

C. The Act of Surrender shall recite that the parent has received a minimum of two pre-surrender counseling sessions or that, in the case of the father, he has waived such counseling in accordance with the requirements of Article 1120. It shall further state that the agency or individual accepting the surrender has no knowledge of any question concerning the mental capacity of the parent that has not been resolved by the court pursuant to Article 1130.1.

D. An act of private surrender shall also recite that the parent has consulted with and been fully advised by an attorney, other than the attorney, associate, partner, shareholder, or employee of the attorney's law firm or corporation for the prospective adoptive parent, about the meaning of these declarations and the effects of the act of surrender in accordance with Article 1123.

E. The Act of Surrender shall be in authentic form and shall be dated and signed by the surrendering parent, the attorney for the surrendering parent, if applicable, and either the adoptive parent or attorney representing the adoptive parent who wishes to remain anonymous, or a representative of the agency. If required by Article 1113, it shall also be signed by the minor's parents or tutor, or the written consent of the court shall be attached.

F. The Act of Surrender for a surrendering mother shall contain the requirements in substantially the following form:

"VOLUNTARY ACT OF SURRENDER FOR ADOPTION

(FOR A SURRENDERING MOTHER OF A CHILD)

STATE OF LOUISIANA

PARISH OF (NAME OF PARISH)

BEFORE ME, the undersigned notary public, and in the presence of the two undersigned competent witnesses who are over the age of eighteen, personally came and appeared:

(NAME OF SURRENDERING MOTHER)

a female of the age of (AGE), who is (MARITAL STATUS), and domiciled in the Parish of (NAME OF PARISH), who being first duly sworn, did depose and state:

(1) She is the mother of (CHILD'S NAME), born on (DATE OF BIRTH) in the (PARISH/COUNTY OF BIRTH), State of (STATE OF BIRTH).

(2) She was married at the birth or conception of the child, or has married subsequent to the child's birth and her husband has acknowledged his paternity of the child. The husband's name is (HUSBAND'S NAME) and his last known address was (ADDRESS OR UNKNOWN).

OR

She was not married at the birth or conception of the child, nor has she, subsequent to the child's birth, married any man who has acknowledged his paternity of the child. To the best of her knowledge, the alleged father has/has not executed an act of acknowledgment/a registration with the putative father registry that admitted his paternity of this child. He has/has not informally acknowledged his paternity of this child. His paternity of this child has/has not been established by court judgment.

(3) The other natural/alleged father of the child is (FATHER'S NAME), and his last known address was (ADDRESS OR UNKNOWN).

(4) The agency to whom this child is hereby surrendered is (NAME OF PERSON, AGENCY OR REPRESENTATIVE), whose address is (ADDRESS), who hereby accepts this surrender is domiciled in this state. The (NAME OF AGENCY) declares that he has no knowledge of any question concerning the parent's capacity to execute a surrender that has not been resolved by the court pursuant to Article 1130.1.

OR

If the surrender is for private adoption, the Person or Representative to whom this child is hereby surrendered is (NAME OF PERSON OR REPRESENTATIVE), whose address is (ADDRESS), hereby accepts this surrender from a surrendering parent who is domiciled in this state or on behalf of adoptive parents domiciled in this state. (NAME OF PERSON OR REPRESENTATIVE) declares that he has no knowledge of any question concerning the parent's capacity to execute a surrender that has not been resolved by the court pursuant to Article 1130.1.

(5) The court in which this surrender is to be filed is (NAME OF JUVENILE COURT) located in (CITY AND PARISH OF COURT) and that said court has jurisdiction over the status of the child by virtue of either a surrendering parent, a prospective adoptive parent, or a legal guardian being domiciled in this state, or that the child is in the custody of the Department of Children and Family Services.

(6) Affiant declares that this Act of Surrender is not being executed earlier than the third day following the birth of the child for agency adoptions or the fifth day following the birth of the child in a surrender for private adoption.

(7) Affiant declares that she has no mental incapacity and is under no interdiction.

(8) Affiant declares that she has been informed and understands that her rights as a parent of the child are permanently and irrevocably terminated by execution of this Act of Surrender; however, she understands that it may be declared null due to fraud or duress and may be dissolved if the adoption cannot be accomplished.

(9)(a) Affiant declares that she freely and voluntarily surrenders custody of the child for the purpose of placement and adoption.

(b) Affiant declares that she has been informed and understands that it is unlawful to willfully and knowingly make a written or oral false statement about the biological paternity of a child and has been advised that the penalties for such falsity are either a fine of ten thousand dollars or imprisonment for not more than five years, or both.

(10) Affiant declares that she consents to an adoption, which consent is final and irrevocable upon execution of this surrender.

(11) Affiant declares that she waives notice of the filing and service of any pleading of any sort in any subsequent adoption proceeding regarding the child surrendered.

(12) Affiant declares that she has been informed of the provisions of the voluntary registration law, whereby contact may be established with the surrendered child upon the child's reaching the age of eighteen years if both the surrendering parent and the adopted person register and fulfill all registration requirements.

(13) Affiant declares that she has attended a minimum of two pre-surrender counseling sessions relative to this surrender of her child for adoption.

(14) Affiant declares that she has been informed and fully advised of the provisions of R.S. 14:125.2 and the penalties provided therein by an attorney, other than the attorney, associate, partner, shareholder, or employee of the attorney's law firm or corporation for the prospective adoptive parent.

(ADDITIONAL DECLARATION IF THE SURRENDER IS FOR AN AGENCY ADOPTION ARRANGED BY THE DEPARTMENT OF CHILDREN AND FAMILY SERVICES)

(15) Affiant declares that the execution of this surrender is made without conditions of any kind. Failure to comply with any formal or informal agreement for post-adoption continuing contact will not nullify the surrender nor constitute cause for revocation.

(ADDITIONAL DECLARATIONS IF THE SURRENDER IS FOR A PRIVATE ADOPTION)

(16) Affiant declares that she is eighteen years of age or older.

OR

Affiant declares that she is under the age of eighteen and that (NAME OF PARENTS OR TUTOR) join in this surrender.

OR

Affiant declares that she is under the age of eighteen and that (NAME OF JUVENILE COURT) located in (CITY AND PARISH OF COURT) has given its written consent for her surrender.

(17) Affiant declares that she has consulted with and been fully advised by an attorney other than the attorney for the prospective adoptive parents about the meaning of these declarations and the consequences of this Act of Surrender.

(18) Affiant declares that she does or does not wish to be notified of the hearing of any opposition to the adoption filed pursuant to Article 1137.

(19) Affiant declares that she does or does not wish the future release of identifying information in the event of a medical necessity for which information is needed in order to treat the child.

(20) Affiant declares that she has been informed and understands that the Statement of Family History will be given to the adoptive parents at the time of placement and made available, upon request, to the adopted person at the age of eighteen years or older.

Sworn to, signed, and notarized, after being carefully read and explained to (NAME OF SURRENDERING PARENT) in the presence of the undersigned notary and witnesses on this _____ day of ____________, 20__.

WITNESSES:

_________________________

_________________________

(If agency adoption:)

_______________________________________

SURRENDERING MOTHER

_______________________________________

AGENCY REPRESENTATIVE

(If private adoption:)

_______________________________________

SURRENDERING MOTHER

_______________________________________

ATTORNEY FOR SURRENDERING MOTHER

_______________________________________

ADOPTING PARENTS

OR

_______________________________________

ATTORNEY FOR ADOPTING PARENTS

(if anonymity to be protected)

(Additional signature(s) in private adoption if the surrendering mother is a minor

_______________________________________

PARENT(S)/TUTOR OF MINOR

SURRENDERING MOTHER)

__________________________________________

NOTARY PUBLIC AND SEAL ATTACHMENTS:

( ) AFFIDAVIT OF MENTAL HEALTH COUNSELOR

( ) STATEMENT OF FAMILY HISTORY

[Required additional attachment if the surrender is for private adoption:

( ) AFFIDAVIT OF ATTORNEY FOR SURRENDERING PARENT]

[Required additional attachment if the surrender is by a minor mother whose parent(s) or tutor refuse to join in the Act of Surrender for a private adoption:

( ) WRITTEN CONSENT OF COURT]"

G. The Act of Surrender for a surrendering father shall contain the requirements in substantially the following form:

"VOLUNTARY ACT OF SURRENDER FOR ADOPTION

(FOR A SURRENDERING FATHER OF A CHILD)

STATE OF LOUISIANA

PARISH OF (NAME OF PARISH)

BEFORE ME, the undersigned notary public, and in the presence of the two undersigned competent witnesses who are over the age of eighteen, personally came and appeared:

(NAME OF SURRENDERING FATHER)

a male of the age of (AGE), who is (MARITAL STATUS), and domiciled in the Parish of (NAME OF PARISH), who being first duly sworn, did depose and state:

(1) He is the natural/alleged father of (CHILD'S NAME), born on (DATE OF BIRTH) in the (PARISH/COUNTY OF BIRTH), State of (STATE OF BIRTH).

OR

He is the natural/alleged father of the child to be born on or about (PROJECTED DATE OF BIRTH) to (MOTHER'S NAME).

(2) He was not married to the child's mother at the time of the child's birth or conception nor has he subsequently married this child's mother and acknowledged his paternity of the child.

OR

He was married to the child's mother at the time of the child's birth or conception.

OR

He has married this child's mother subsequent to the child's birth and has acknowledged his paternity of the child.

OR

He was not married to and has not married the mother of this child/expected child. He has/has not executed an act of formal acknowledgment/a registration with the putative father registry that admitted his paternity of this child/expected child. He has/has not informally acknowledged his paternity of this child/expected child. His paternity of this child/expected child has/has not been established by court judgment.

(3) The natural mother of the child/expected child is (MOTHER'S NAME), and her last known address was (ADDRESS OR UNKNOWN).

(4) The agency to whom this child is hereby surrendered is (NAME OF PERSON, AGENCY OR REPRESENTATIVE), whose address is (ADDRESS), who hereby accepts this surrender is domiciled in this state. The (NAME OF AGENCY) declares that he has no knowledge of any question concerning the parent's capacity to execute a surrender that has not been resolved by the court pursuant to Article 1130.1.

OR

If the surrender is for private adoption, the Person or Representative to whom this child is hereby surrendered is (NAME OF PERSON OR REPRESENTATIVE), whose address is (ADDRESS), hereby accepts this surrender from a surrendering parent who is domiciled in this state or on behalf of adoptive parents domiciled in this state. (NAME OF PERSON OR REPRESENTATIVE) declares that he has no knowledge of any question concerning the parent's capacity to execute a surrender that has not been resolved by the court pursuant to Article 1130.1.

(5) The court in which this surrender is to be filed is (NAME OF JUVENILE COURT) located in (CITY AND PARISH) and that said court has jurisdiction over the status of the child by virtue of either a surrendering parent, a prospective adoptive parent, or a legal guardian being domiciled in this state, or that the child is in the custody of the Department of Children and Family Services.

(6) Affiant declares that this Act of Surrender is/is not being executed earlier than the third day following the birth of the child for agency adoptions, or the fifth day following the birth of the child in a surrender for private adoption.

(7) Affiant declares that he has no mental incapacity and is under no interdiction.

(8) Affiant declares that he has been informed and understands that his rights as a natural parent/alleged parent of the child/expected child less than five days old are permanently and irrevocably terminated on the fifth day following the birth of the child; however, he understands that this Act of Surrender may be declared null due to fraud or duress and may be dissolved if the adoption cannot be accomplished.

OR

Affiant declares that he has been informed and understands that his rights as a natural parent/alleged parent of the child are permanently and irrevocably terminated by execution of this Act of Surrender; however, he understands that it may be declared null due to fraud or duress and may be dissolved if the adoption cannot be accomplished.

(9)(a) Affiant declares that he freely and voluntarily surrenders custody of this child for the purpose of placement and adoption.

(b) Affiant declares that he has been informed and understands that it is unlawful to willfully and knowingly make a written or oral false statement about the biological paternity of a child and has been advised that the penalties for such falsity are either a fine of ten thousand dollars or imprisonment for not more than five years, or both.

(10) Affiant declares that he consents to an adoption, which consent is final and irrevocable on the third day following the birth of this child/expected child for agency adoptions, and on the fifth day following the birth of this child/expected child less than five days old if this is a private adoption.

OR

Affiant declares that he consents to an adoption, which consent is final and irrevocable upon the execution of this surrender.

(11) Affiant declares that he waives notice of the filing and service of any pleading of any sort in any subsequent adoption proceeding regarding the child surrendered.

(12) Affiant declares that he has been informed of the provisions of the voluntary registration law, whereby contact may be established with the surrendered child upon the child's reaching the age of eighteen years if both the surrendering parent and the adopted person register and fulfill all registration requirements.

(13) Affiant declares that he has attended a minimum of two pre-surrender counseling sessions relative to the surrender of this child for adoption.

OR

Affiant declares that he waives pre-surrender counseling relative to the surrender of this child for adoption.

(14) Affiant declares that he has been informed and fully advised of the provisions of R.S. 14:125.2 and the penalties provided therein by an attorney, other than the attorney, associate, partner, shareholder, or employee of the attorney's law firm or corporation for the prospective adoptive parent.

(ADDITIONAL DECLARATION IF THE SURRENDER IS FOR AN AGENCY ADOPTION ARRANGED BY THE DEPARTMENT OF CHILDREN AND FAMILY SERVICES)

(15) Affiant declares that the execution of this surrender is made without conditions of any kind. Failure to comply with any formal or informal agreement for post-adoption continuing contact will not nullify the surrender nor constitute cause for revocation.

(ADDITIONAL DECLARATIONS IF THE SURRENDER IS FOR A PRIVATE ADOPTION)

(16) Affiant declares that he is eighteen years of age or older.

OR

Affiant declares that he is under the age of eighteen and that (NAME OF PARENTS OR TUTOR) join in this surrender.

OR

Affiant declares that he is under the age of eighteen and that (NAME OF JUVENILE COURT) located in (CITY AND PARISH OF COURT) has given its written consent for his surrender.

(17) Affiant declares that he has consulted with and been fully advised by an attorney other than the attorney for the prospective adoptive parents about the meaning of these declarations and the consequences of this Act of Surrender.

(18) Affiant declares that he does or does not wish the future release of identifying information in the event of a medical necessity for which information is needed in order to treat the child.

(19) Affiant declares that he has been informed and understands that the Statement of Family History will be given to the adoptive parents at the time of placement and made available, upon request, to the adopted person at the age of eighteen years or older.

Sworn to, signed, and notarized, after being carefully read and explained to (NAME OF SURRENDERING PARENT) in the presence of the undersigned notary and witnesses on this _____ day of ____________, 20__.

WITNESSES:

_________________________

_________________________

(If agency adoption:)

_______________________________________

SURRENDERING FATHER

_______________________________________

AGENCY REPRESENTATIVE

(If private adoption:)

_______________________________________

SURRENDERING FATHER

_______________________________________

ATTORNEY FOR SURRENDERING FATHER

_______________________________________

ADOPTING PARENTS

OR

_______________________________________

ATTORNEY FOR ADOPTING PARENTS

(if anonymity to be protected)

[Additional signature(s) in private adoption if the surrendering father is a minor

_______________________________________

PARENT(S)/TUTOR OF MINOR

SURRENDERING FATHER]

__________________________________________

NOTARY PUBLIC AND SEAL ATTACHMENTS:

( ) AFFIDAVIT OF MENTAL HEALTH COUNSELOR or AFFIDAVIT OF WAIVER OF COUNSELING

( ) STATEMENT OF FAMILY HISTORY

[Required additional attachment if the surrender is for private adoption:

( ) AFFIDAVIT OF ATTORNEY FOR SURRENDERING PARENT]

[Required additional attachment if the surrender is by a minor father whose parent(s) or tutor refuse to join in the Act of Surrender for a private adoption:

( ) WRITTEN CONSENT OF COURT]"

H. A copy of the Act of Surrender shall be made available to a surrendering parent at the time it is executed, or upon request, at any time thereafter.

Acts 1991, No. 235, §11, eff. Jan. 1, 1992; Acts 1992, No. 705, §1, eff. July 6, 1992; Acts 1993, No. 634, §1, eff. June 15, 1993; Acts 1995, No. 1095, §5; Acts 1999, No. 1243, §2, eff. Jan. 1, 2000; Acts 2001, No. 953, §2; Acts 2001, No. 1064, §2; Acts 2003, No. 567, §1; Acts 2008, No. 583, §1; Acts 2008, No. 584, §1; Acts 2010, No. 266, §1; Acts 2016, No. 434, §1; Acts 2018, No. 296, §1.