Schedule XX
[See regulation 52(2) and 55(2)]
CONSENT OF BIOLOGICAL PARENT(S) ALONG WITH
STEP- PARENT TO OBTAIN THE PERMISSION OF CHILD
WELFARE COMMITTEE FOR ADOPTION OF
CHILD/CHILDREN BY BIOLOGICAL PARENT AND THE
STEP-PARENT
A. I/We the undersigned:
Biological Father Biological Mother
Family name: .......................... Family name: ..................................
First name: First name:
................................................... ...................................................
Date of birth: day ....month ....year ... Date of birth: day ....month ....year ...
Permanent Permanent
Address: Address:
.............................................. ..............................................
(i) hereby relinquish/surrender my/our natural right/claim with my/our
child/children ----------------------------------- (name, gender, date of birth).
(ii) understand that the adoption of this child will create a permanent and
legal parent-child relationship with the step-parent & the biological
parent adopting the child.
(iii) certify that the child/children has/have given his/her/their consent for
the said adoption and is/are willing to accept the step-parent adopting
the child/children as father/mother (strike out which is not applicable).
(iv) certify that my/our consent above is given out of free will and has not
been induced by payment or compensation of any kind.
(v) declare that I/we have fully understood the above statements.
Signed at ................ on..............
(Signature or Thumb Impression of the biological parent(s))
Biological Father Biological Mother
B. Consent of the child /children at A (i), if completed five years of
age before Child Welfare Committee.
Countersigned by Biological Parent(s)
C. Step Parent & the Biological Parent Adopting the Child/Children.
Family name: ..........................
First name(s): ...................................................
Date of birth: day ....month ....year ...
Permanent
Address: ..............................................
We, the undersigned:
(i) give our consent to adopt the child/children mentioned at A (i) above,
out of our free will.
(ii) understand that the adoption of the child/children will create a
permanent parent-child relationship with all the rights and duties
associated with such relationship.
(iii) declare that we have fully understood the above statements.
Signed at ................ on..............
(Signature or Thumb Impression of the step-parent & the biological
parent)
Step-Parent Biological Parent
D. Declaration by Witnesses
We, the undersigned have witnessed the above.
(a) Signature, Name and Address of the first Witness with ID proof
...........................................................................
...........................................................................
(b) Signature, Name and Address of the second Witness with ID proof
..........................................................................
...........................................................................
Signed at ................ on ..............
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