California Code of Regulations › Title 22 - Social Security › Division 2 - Department of Social Services-Department of Health Services › Part 2 - Health and Welfare Agency-Department of Health Services Regulations › Subdivision 4 - Institutions and Boarding Homes for Persons Aged 16 and Above › Chapter 3 - Adoptions Program Regulations [Renumbered] › Subchapter 2 - General Requirements › Article 1 - Correction, Alteration, Translation and Reading of Forms › Section 35001 - Definitions-Forms

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
The following forms, which are incorporated by
							 reference, apply to the regulations in Title 22, Division 2, Subdivision 4,
							 Chapter 3 (Adoption Program Regulations).
(a)
(1)
						  "AAP 1" (9/09) means the form entitled, "Request for Adoption Assistance
						  Program Benefit."
(2) "AAP 2"
						  (7/11) means the form entitled, "Payment Instructions -- Adoption Assistance
						  Program."
(3) "AAP 3" (7/11) means
						  the form entitled, "Reassessment Information -- Adoption Assistance
						  Program."
(4) "AAP 4" (11/11) means
						  the form entitled, "Eligibility Certification -- Adoption Assistance
						  Program."
(5) "AAP 6" (11/11) means
						  the form entitled, "Adoption Assistance Program -- Negotiated Benefit Amount
						  and Approval and Form Instructions."
(6) "AAP 8" (11/11) means the form entitled,
						  "Adoption Assistance Program -- Nonrecurring Adoption Expenses
						  Agreement."
(7) "AD 1A" (4/15)
						  means the form entitled, "Parental Consent to Adoption (In or
						  Out-of-California)."
(8) "AD 1F"
						  (4/15) means the form entitled, "Parental Consent to Adoption (Outside
						  California in the Armed Forces)."
(9) "AD 8" (10/01) means the form entitled,
						  "Marriage/Divorce Verification."
(10) "AD 9" (11/07) means the form entitled,
						  "Independent Adoption Questionnaire."
(11) "AD 10" (9/03) means the form entitled,
						  "Request for Reference."
(12) "AD
						  20" (4/15) means the form entitled, "Refusal to Give Parental Consent to
						  Adoption (Birth Mother/Presumed/Biological Father/Legal Parent)."
(13) "AD 20B" (5/15) means the form entitled,
						  "Refusal to Give Parental Consent to Adoption--Alleged Father."
(14) "AD 42 I" (3/02) means the form
						  entitled, "Independent Adoption Program -- Individual Case Report."
(15) "AD 42R" (7/95) means the form entitled,
						  "Relinquishment Adoption Program -- Individual Case Report."
(16) "AD 65" (2/02) means the form entitled,
						  "Parent's Authorization for Medical and Surgical Care."
(17) "AD 67" (5/15) means the form entitled,
						  "Information About the Birth Mother."
(18) "AD 67A" (7/15) means the form entitled,
						  "Information About the Birth Father."
(19) "AD 90" (6/13) means the form entitled,
						  "Supporting Information for Issuance of California Department of Social
						  Services Acknowledgment and Confirmation of Receipt of Child Freeing
						  Documents."
(20) "AD 100" (7/10)
						  means the form entitled, "Authorization for Use and/or Disclosure of
						  Information Independent Adoption Program."
(21) "AD 100A" (7/20) means the form
						  entitled, "Authorized for Release, Use and/or Disclosure of Health Information
						  Agency Adoption Program."
(22) "AD
						  165" (3/15) means the form entitled, "Presumed Father's Consent to Adoption
						  When Denying He is the Biological Father (In or Out-of-California)."
(23) "AD 501 ENG/SP" (12/91) means the form
						  entitled, "Relinquishment (Birth Mother and/or Presumed Father)."
(24) "AD 501A ENG/SP" (12/91) means the form
						  entitled, "Relinquishment (Out of State)."
(25) "AD 503 ENG/SP" (12/91) means the form
						  entitled, "Relinquishment -- Out of County (Birth Mother and/or Presumed
						  Father)."
(26) "AD 504 ENG/SP"
						  (12/91) means the form entitled, "Relinquishment -- Out of State -- in-Armed
						  Forces."
(27) "AD 508 ENG/SP"
						  (3/82) means the form entitled, Rescission Request/Rescission of
						  Relinquishment."
(28) "AD 512"
						  (1/14) means the form entitled, "Psychosocial and Medical History of
						  Child."
(29) "AD 551A" (3/94) means
						  the form entitled, "Notification of Procedure in Lieu of Signing Relinquishment
						  Waiver or Denial."
(30) "AD 558"
						  (8/97) means the form entitled, "Notice of Placement."
(31) "AD 580" (6/97) means the form entitled,
						  "Notice of Removal of Child from Adoptive Home."
(32) "AD 583 Eng/Sp" (6/95) means the form
						  entitled, "Relinquishment -- Out of County (Presumed Father Denies He is the
						  Birth Father)."
(33) "AD 584
						  Eng/Sp" (8/95) means the form entitled, "Relinquishment -- Out of State
						  (Presumed Father Denies He is the Birth Father)."
(34) "AD 586 Eng/Sp" (6/97) means the form
						  entitled, "Relinquishment -- In or Out of County (Alleged Natural Father in
						  California)."
(35) "AD 588" (4/15)
						  means the form entitled, "Denial of Paternity by Alleged Father -- (In or
						  Out-of-California)."
(36) "AD 590"
						  (4/15) means the form entitled, "Waiver of Right to Further Notice of Adoption
						  Planning (Alleged Father In or Out-of-California)."
(37) "AD 591 Eng/Sp" (12/91) means the form
						  entitled, "Relinquishment (Alleged Natural Father) Out of State or
						  County."
(38) "AD 593" (12/91)
						  means the form entitled, "Relinquishment (Alleged Natural Father) Outside of
						  California in Armed Forces."
(39)
						  "AD 594" (3/15) means the form entitled, "Alleged Father's Consent to Adoption
						  (In or Out-of-California)."
(40)
						  "AD 824" (5/97) means the form entitled, "Consent and Joinder" for agency
						  adoptions.
(41) "AD 830" (9/97)
						  means the form entitled, "Summary Claim for Reimbursement Private Adoption
						  Agency Reimbursement Program."
(42)
						  "AD 842" (3/17) means the form entitled, "Alleged Father's Consent to Adoption
						  (Outside California in the Armed Forces)."
(43) "AD 859" (8/15) means the form entitled,
						  "Parental Consent to Adoption of Indian Child (In or
						  Out-of-California)."
(44) "AD 860"
						  (8/15) means the form entitled, "Presumed Father's Consent to Adoption of
						  Indian Child (In or Out-of-California)."
(45) "AD 861" (8/15) means the form entitled,
						  "Alleged Father's Consent to Adoption of Indian Child (In or
						  Out-of-California)."
(46) "AD 862"
						  (12/91) means the form entitled, "Relinquishment of Indian Child by Alleged
						  Natural Father -- Out of State or County."
(47) "AD 863" (12/91) means the form
						  entitled, "Relinquishment of Indian Child -- Out of State."
(48) "AD 864" (1/92) means the form entitled,
						  "Relinquishment of Indian Child (Birth Mother and/or Presumed
						  Father)."
(49) "AD 866" (8/95)
						  means the form entitled, "Relinquishment of Indian Child (Presumed Father
						  Denies He is the Birth Father)."
(50) "AD 867" (6/95) means the form entitled,
						  "Relinquishment of Indian Child (Presumed Father Denies He is the Birth Father)
						  Out of State."
(51) "AD 868" (1/92)
						  means the form entitled, "Relinquishment of Indian Child (Alleged Natural
						  Father in California) In/Out of County."
(52) "AD 880" (9/15) means the form entitled,
						  "Declaration of Mother."
(53) "AD
						  885" (7/98) means the form entitled, "Statement of Understanding -- Agency
						  Adoptions Program (Mother or a Presumed Father of the Child Who Is Not
						  Detained, a Juvenile Court Dependent in Out-of-Home Care, or the Ward of a
						  Legal Guardian)."
(54) "AD 885A"
						  (9/98) means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Mother or a Presumed Father of a Child Who Is Detained, a Juvenile
						  Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(55) "AD 885C" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Alleged Natural Father of the Child Who Is Not Detained, a Juvenile
						  Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(56) "AD 885D" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Alleged Natural Father of the Child Who Is Detained, a Juvenile Court
						  Dependent in Out-of-Home Care, or the Ward of a Legal Guardian)."
(57) "AD 887" (3/18) means the form entitled,
						  "Statement of Understanding -- Independent Adoptions Program Parent Who Gave
						  Physical Custody (Custodial Parent) of the Child to the
						  Petitioner(s))."
(58) "AD 887A"
						  (3/18) means the form entitled, "Statement of Understanding -- Independent
						  Adoptions Program (Parent Who Did Not Give Physical Custody (Non-Custodial
						  Parent) of the Child to the Petitioner(s))."
(59) "AD 887B" (3/18) means the form
						  entitled, "Statement of Understanding -- Independent Adoptions Program (Alleged
						  Father)."
(60) "AD 898" (1/11)
						  means the form entitled, "Consent of California Department of Social Services
						  or Delegated County Adoption Agency -- Independent Adoptions
						  Program."
(61) "AD 899" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Mother or a Presumed Father of the Indian Child Who Is Not Detained, a
						  Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(62) "AD 899A" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Mother or a Presumed Father of an Indian Child Who Is Not Detained, a
						  Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(63) "AD 899C" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Alleged Natural Father of the Indian Child Who Is Not Detained, a
						  Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(64) "AD 899D" (7/98)
						  means the form entitled, "Statement of Understanding -- Agency Adoptions
						  Program (Alleged Natural Father of the Indian Child Who Is Not Detained, a
						  Juvenile Court Dependent in Out-of-Home Care, or the Ward of a Legal
						  Guardian)."
(65) "AD 900" (8/18)
						  means the form entitled, "Statement of Understanding -- Independent Adoptions
						  Program (Parent Who Gave Physical Custody (Custodial Parent) of the Indian
						  Child to the Petitioner(s))."
(66)
						  "AD 900A" (3/18) means the form entitled, "Statement of Understanding --
						  Independent Adoptions Program (Parent Who Did Not Give Physical Custody
						  (Non-Custodial Parent) of the Indian Child to the Petitioner(s))."
(67) "AD 900B" (3/18) means the form
						  entitled, "Statement of Understanding -- Independent Adoptions Program (Alleged
						  Father of Indian Child)."
(68) "AD
						  904" (7/11) means the form entitled, "Consent for Contact."
(69) "AD 904A" (12/10) means the form
						  entitled, "Waiver of Rights to Confidentiality for Siblings."
(70) "AD 904B" (1/11) means the form
						  entitled, "Waiver of Rights to Confidentiality for Siblings -- Under the Age of
						  18."
(71) "AD 907" (5/94) means the
						  form entitled, "Adoptive Placement Agreement."
(72) "AD 908" (9/15) means the form entitled,
						  "Adoptions Information Act Statement."
(73) "AD 908A" (1/11) means the form
						  entitled, "Adoptions Information Act Statement (Adult Adoptee (age 21 or
						  older))."
(74) "AD 909" (8/88)
						  means the form entitled, "Photolisting Data Sheet."
(75) "AD 924" (5/15) means the form entitled,
						  "Independent Adoption Placement Agreement."
(76) "AD 925" (8/15) means the form entitled,
						  "Independent Adoption Placement Agreement -- (Indian Child)."
(77) "AD 926" (1/18) means the form entitled,
						  "Statement of Understanding -- Independent Adoption Program (Parent Who Places
						  the Child with the Prospective Adoptive Parent(s))."
(78) "AD 927" (3/18) means the form entitled,
						  "Statement of Understanding -- Independent Adoption Program (Parent Who Places
						  the Indian Child with the Prospective Adoptive Parent(s))."
(79) "AD 928" (7/02) means the form entitled,
						  "Revocation of Consent -- Independent Adoption Program."
(80) "AD 929" (9/18) means the form entitled,
						  "Waiver of Right to Revoke Consent -- Independent Adoption Program."
(81) "AD 929A" (4/21) means the form
						  entitled, "Waiver of Right to Revoke Relinquishment -- Agency Adoption
						  Program."
(82) "AD 930" (7/11)
						  means the form entitled, "Independent Adoption Placement Agreement
						  Transmittal."
(83) "AD 4310" (1/93)
						  means the form entitled, "Adoption Programs Notice Required by Information
						  Practices Act."
(84) "AD 4317"
						  (3/82) means the form entitled, "Revocation of Relinquishment."
(85) "AD 4320" (11/11) means the form
						  entitled, "Adoption Assistance Program Agreement."
(86) "AD 4333" (8/14) means the form
						  entitled, "Acknowledgement or Confirmation of Receipt of Child Freeing
						  Documents."
(87) "AD 4336" (4/15)
						  means the form entitled, "Presumed Father's Consent to Adoption When Denying He
						  is the Biological Father (Outside of California in the Armed
						  Forces)."
(88) "ADM 36" (6/99)
						  means the form entitled, "Medical Report Regarding Child to be
						  Adopted."