This form is to be used for entrustment agreement for permanent surrender of a child.Download
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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)Relevant article from our knowledge database
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