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).
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Signature and Title