CERTIFICATE OF RELINQUISHMENT

This certifies that the attached document, executed on (Date), by

_____________________________ (Name) of _____________________________
__________________________________ (Address), relinquishing custody of the child named
_________________________ (Name), to _____________________________, an agency authorized to
place children for adoption in a suitable home, was executed in accordance with the laws of
___________________________ (State); and that the above-named child was placed for adoption with
_____________________________ and ______________________________ (Names), of
_____________________________________________________(Address), who ____________
(Has/Have) filed a petition to formally adopt the above-named child in the Court of
_____________________________________________ (Name and Address of Court).

Approval is granted for completion of the above-referenced adoption.

In witness whereof, I have signed this instrument in my capacity as the duly authorized representative of
________________________________________ (Agency).

_______________________ _____________

Signature and Title Date