Surrender of Parental Rights

The following form has to be completed by any parents who are surrendering their parental right. The mentioned form is used to specify the rights that are being surrendered.

Extracted Text for Proper Search

NHJB-2080-FP (10/01/2009) Page 1 of 3 	
 
 	THE STATE OF NEW HAMPSHIRE	 	
JUDICIAL BRANCH 
http://www.courts.state.nh.us	 	
 	
Court Name: 
Case Name: 
Case Number: 
  (if known) 	
 
Surrender of Parental Rights over   
 	
SURRENDER OF PA RENTAL RIGHTS 	
Of:       	  Birth Mother       	  Birth Father        	  Legal Father 
(RSA 170-B:5 through 170-B:12)   
1.  Name of parent surrendering rights     	
Telephone      City/town, state of residence        	
  Mailing Address     
  Date of Birth   Place of Birth   
2.  Attorney for surrendering parent     Telephone   
  Mailing Address    
3.  Name of other parent     	
Telephone      City/town, state of residence        	
  Mailing Address    
  Date of Birth   Place of Birth   
4.  Child Name     
  Date of Birth   Place of Birth   
5.  Is the child an Indian child as defined by the Indian Child Welfare Act? 	  Yes 	  No 
 If yes, name and address of tribe            	
Is tribe recognized by the federal government as e ligible for federal services or certain Alaskan 
native corporations as defined in 43 U.S.C. §1602(c)? 	
  Yes 	  No 
6.  Birth mother’s marital status:    	
  Single     	  Married     	   Divorced     	  Widowed    
If married, divorced or widowed, nam e of spouse          	
If applicable, date of marriage    date of divorce          	
7.  Do you know the identity of the adoptive parents? 	  Yes 	  No 
8.  Are there any pending adoption, termination of parental rights, juvenile, domestic violence,  marriage dissolution, domestic relations, paternity , legitimation, custody or other proceedings 
affecting minor or paren ts of this minor?   	
  Yes     	  No        If yes, attach a separate sheet 
identifying and explaining each.

Case Name: Surrender of Parental Rights over   
Case Number:    
SURRENDER OF PARENTAL RIGHTS  
NHJB-2080-FP (10/01/2009) Page 2 of 3 
Please read carefully or complete the information below before signing this document. 
By completing this surrender of parental rights,  I understand that my parental rights over the child, 
including the rights of care, cust ody and control of the child, will ce ase when the court approves this 
surrender.  I also waive any right to receive  any notices about future hearings about the child. 
 
I understand that after the court approves this  surrender, all my parental obligations will be 
extinguished, except the obligation  to pay any accrued unpaid child support. 
 
I understand that after the court approves this su rrender in compliance with New Hampshire law, the 
surrender is final, and may not be revoked or set asi de for any reason, unless the court finds that the 
surrender was obtained by fr aud or duress, and that the withdrawal of the surrender is in the best 
interests of the adoptee.  The failure of an adoptive parent to comply with an arrangement or 
understanding reached with t he birth parent with respect to the pos t-surrender exchange of identifying 
or non-identifying information, comm unication or contact is not a reason to revoke or set aside a 
surrender.  
 
I have been informed that child placing agencies dul y licensed pursuant to RSA 170-E are available 
to counsel me about my decision to  surrender my parental rights. 
 
I have been provided legal counsel, unless  waived with approval of the court. 
 
I have not received or been promised any money or  anything of value for the completion of this 
surrender, except for payments pe rmissible under New Hampshire law.  They are as follows: 
       
      
By signing this document below, I declare: 
   that I am the parent  of the above named child; 
    that all the information on this surrender form is true; 
    that I have read and understand t he content of this document; 
    that all of my questions have been answered by the court or its design\
ee; 
    that I wish this surrender of  parental rights to take effect; and 
    that (please check one of the following): 
  	  I do not wish to receive confirmation of the final adoption of this child. 
  
  I wish to receive confirmation of  the final adoption of this child. 
     	
Date      Signature 	
 
State of     , County of      	
This instrument was acknowledged bef ore me on        by            
My Commission Expires       
Affix Seal, if any           	Signature of Judge / Notarial Officer / Title

Case Name: Surrender of Parental Rights over   
Case Number:    
SURRENDER OF PARENTAL RIGHTS  
NHJB-2080-FP (10/01/2009) Page 3 of 3 
If the surrendering parent is a minor or under guardianship,  complete the following section. 
 We,         , are the parents or guardians of the 
named birth parent who is surrendering his/her rights,  and hereby give our assent to this surrender. 
     
Signature / Relationship  Address 
     
Signature / Relationship  Address 
 
 
State of     , County of      
This instrument was acknowledged bef ore me on        by            
My Commission Expires       
Affix Seal, if any           	Signature of Notarial Officer / Title	 
 
  ORDER 	
 
This surrender of parental rights is:    	
  Approved        	  Not approved 
     	
Date Judge