GEORGIA DEPARTMENT OF HUMAN RESOURCES

AFFIDAVIT OF CONSENT TO ADOPTION

(Affidavit 2)
GEORGIA,

COUNTY

Before me, the undersigned, attesting officer authorized to administer oaths, came , Director/Designee,
County Department of Family and Children Services, Georgia Department of Human Resources, who duly sworn,
deposed as follows:

That on

the custody and control of a

(Date of Surrender)

Male/Female

child, , born ,
(Childs Birth Name)
(DOB)

was surrendered to the Georgia Department of Human Resources by the of said child.
(Relationship of Person Who Surrendered)
The surrender of said child was taken under authority of Section 19-8-4 (a) (1) of the Code of Georgia Annotated, as amended, and is
evidenced by documents executed in accordance with the provisions of Section 19-8-4 (c)(d)(e)(f)(g)(h)(i)(j) of the Code of Georgia
Annotated, as amended, by the of said child. Certified copies attached.
(Relationship of Person Who Surrendered)
That, in the documents, the did expressly waive any other notice or further service in any of the legal proceedings
(Relationship of Person Who Surrendered)
for the adoption of said child; That on following termination of rights on the , the custody and control
(Date TPR)
(Relationship of Person Whose Rights Terminated)

of this same
Male/Female

child ,
(Birth Name of Child)

born , was placed in

(DOB)
(Relative(s) Name(s)

for the purpose of adoption by the Juvenile Court of County, Judge presiding.
(Name of Judge)
That commitment of said child was given under authority of Section 15-11-90 (a) (1) of the Code of Georgia Annotated, as amended;
That the provisions of Sections 19-8-4 (c)(d)(e)(f)(g)(h)(i) and 19-8-12 of the Code of Georgia Annotated, as amended, are not
applicable to the ;
(Relationship of Person Whose Rights Terminated)
That said child, now in the custody of said adoptive parent(s), is one and the same as the child whose custody and control was
surrendered to and placed with the Georgia Department of Human Resources as above stated;
That it is indicated that adoption by and said adoptive parent will be for the best interest of said child, and
THEREFORE, I, Director/Designee, County Department of Family and Children Services,
on behalf of the Georgia Department of Human Resources, do hereby consent to the adoption of the aforesaid child by
.
(Name(s) of Relatives)
The Department of Human Resources requests that this consent be incorporated into the above permanent custody order to avoid
any future custody conflict.
THIS THE DAY OF , 20

Director/Designee
County Department of Family and
Children Services

SWORN TO AND SUBSCRIBED BEFORE ME THIS THE

DAY OF , 20
ADP 197 Affidavit of Consent to Adoption (Affidavit 2) (Rev. 6-05)

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, Notary Public

ADP 197 Affidavit of Consent to Adoption (Affidavit 2) (Rev. 6-05)

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