Mississippi Administrative Code › Title 18 - HUMAN SERVICES › Part 6 - Division of Family and Children's Services › Chapter 1 - DFCS Policy Manual › Section 18-6-1-G - Adoption Policy › ADOPTION ASSISTANCE › Section 18-6-1-G-XII - APPENDICES › Appendix 18-6-1-G-XII-A - Form 459- Surrender of Parental Rights/Consent to Adoption

Current through June 25, 2024
Surrender of Parental Rights and Consent to Adoption to
						  the Mississippi Department of Human Services
KNOW ALL MEN BY THESE PRESENTS, that I,
						  _____________________ (name of parent) being the ____________ (relationship to
						  child) of ______________________ (full name of child, as on birth certificate)
						  a male/female minor who was born on ____________ , ______ at ________________ ,
						  _____________ (date of birth/ city/ state) being of the opinion that it is in
						  the best interest of my said child that he/she be placed under the exclusive
						  care, custody and control of the Mississippi Department of Human Services, an
						  administrative agency of the State of Mississippi, and that he/she be free for
						  adoption, I do hereby relinquish and surrender all my parental rights to said
						  child to the Mississippi Department of Human Services and enter my consent to
						  said adoption, and by these presents do hereby make, constitute and appoint the
						  Director, Office of Social Services, in his/her official capacity, and his/her
						  successors in office, or his/her duly authorized agent or representative, to
						  exercise exclusive care, custody and control over the person and estate of said
						  child. I do also hereby grant and give unto said Director, and his/her
						  successors in office, or his/her duly authorized agent, full power and
						  authority to do and perform any and all acts which he/she may deem to be in the
						  best interest of my said child, including, but not limited to, the authority to
						  consent to the adoption of said child. This relinquishment includes the rights
						  of inheritance, provided the rights of inheritance shall not be affected until
						  the entry of a final decree of adoption.
That this SURRENDER OF PARENTAL RIGHTS AND CONSENT TO
						  ADOPTION is irrevocable, and that I will not, in any manner whatsoever at any
						  time hereafter, interfere with the custody of my said child or attempt to
						  assert any parental or other rights in connection with said child;
That I hereby understand that the signing of this form
						  expressly waives any service of process or any summonses, or any notice of any
						  kind in any court proceedings regarding the welfare or the adoptive placement
						  of the aforesaid child;
That I have freely and voluntarily entered into this
						  agreement, after careful consideration. I fully understand the meaning of this
						  document and the consequences of my decision to voluntarily give up my parental
						  rights to my child. I further state that no one has threatened nor otherwise
						  pressured me to sign this document, nor has anything been offered or received
						  for my signing of this form.
WITNESS my signature on this, the _______ day of
						  ____________ , A.D., 20 __________ .
WITNESS: Parent's SIGNATURE:
__________________________
						  ____________________________
STATE OF _______________________
COUNTY OF _____________________
THIS DAY, personally came and appeared before me, the
						  undersigned authority, in and for the aforesaid County and State, the within
						  named _____________________________________________ , who acknowledged to me
						  that he/she signed and delivered the above the foregoing written instrument on
						  the day and year therein mentioned as his/her own free act and deed.
GIVEN UDNER MY HAND AND OFFICIAL SEAL of office on
						  this, the ____day of ________ A.D., 20 ________ .
______________________
						  ________________________________
My Commission Expires: NOTARY PUBLIC