Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-A
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
Miss. Code. tit. 18, pt. 6, ch. 1, 18-6-1-G, ADOPTION ASSISTANCE, 18-6-1-G-XII, app 18-6-1-G-XII-A