Entrustment Agreement for Permanent Surrender of a Child

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COMMONWEALTH OF VIRGINIA 	
Virginia Department of Social Services 	
 
ENTRUSTMENT AGREEMENT FOR PERMANENT SURRENDER OF A CHILD 	
(COMPLETE ONE DOCUMENT FOR EACH PARENT) 	
 
This Entrustment Agreement for Permanent Surrender of a Child, (hereinafter 
referred to as the “Agreement”) is ent ered into this_____ day of_____, 200_____ 
in the City/County of _________________, State of ____________, between the 
Mother____________, 	
or	  Father___________ o f,________________________ 
(a child under the age of ei ghteen) born on_______ day of_____, _____ , 
(hereinafter referred to as the “child”),  and the City/County of Local Board of 
Social Services, (hereinafter  referred to as the “Board”). 	
 
The Mother or Father, after having been provided  an opportunity for counseling 
and after due consideration of alternativ e plans for the child, hereby voluntarily 
agrees to surrender legal custody of the  child, which includes all legal rights and 
obligations with respect to  the child, to the Board. 
 
The Mother or Father, hereby indicate s his/her understanding and 
acknowledgement that the  signing of the Agreement, by  all parties, constitutes 
his/her permanent separation from and terminat ion of all his/her legal rights and 
obligations to the child, and the child w ill be free from all legal obligations of 
obedience and maintenance from them, from the effective date of the 
Agreement. 
 
It is understood by all parties that this Ag reement may be revoked by either of the 
biological parents until the child has  reached ten days old and seven days have 
elapsed from the signing of this Agreem ent. It is further understood that this 
Agreement may be revoked any time prior to  the termination of parental rights by 
the juvenile court followi ng a petition for approval of  the entrustment agreement 
§16.1-277.01,  Code of Virginia . 
 
The Mother or Father hereby grants to  the Board full custody over the child, with 
all rights and responsibilities to plan fo r the child’s future care, protection, 
maintenance, including the right to place the child for adoption and to consent to 
the adoption of the child  pursuant to §§ 63.2-1221–1223,  Code of Virginia. 
 
Pursuant to § 63.2-1222,  Code of Virginia, this Agreement is valid without the 
signature of the birth father of a child born out of wedl ock if the identity of the 
father is not reasonably ascertainable; or  the father has been given notice of the 
Agreement and failed to object; or the  birth father has been convicted of a 
violation of subsection A of §18.2-61, §18.2-63 or s ubsection B of §18.2-366, 
Code of  Virginia,  and the child was conceived as  a result of the violation. 
 
The Board hereby accepts legal custody and assumes full responsibility for the 
child and agrees to care for, maintain,  protect and plan for the child in a manner 
conducive to the best interests of the child and the State.

In witness whereof, all parties received a copy of the Agreement pursuant to § 
63.2-1222,  Code of Virginia . 
 
__________________________________________ __________ 	
MOTHER or FATHER              DATE 	
 
________________________ __________________ ___________ 	
REPRESENTATIVE OF THE BOARD       DATE 	 
STATE OF VIRGINIA 
COUNTY/CITY OF ___________________ ___________________, ss: 
 
I, _______________________________ _____________________, a notary  
 
public in and for the County/City aforesaid, do certify that 
________________________ __________________________,whose name is  
 
signed first to the writing above, has acknowledged the same before me on this  
 
day of___________, 20________ . 
 
________________________ _________________________, Notary Public 
 
 
My commission expires: ________________ _____________. 
 
 
STATE OF VIRGINIA 
COUNTY/CITY OF ___________________ ___________________, ss: 
 
I, _______________________________ _____________________, a notary  
 
public in and for the County/City aforesaid, do certify that 
________________________ __________________________, whose name is  
 
signed last to the writing above, has acknowledged the same before me on this 
day of_____________, 20_________ . 
 
________________________ _________________________, Notary Public 
 
 
My commission expires: _____________ ________________.	 	  032-02-0024-04-eng (08/06)