In the heart of California's efforts to connect birth parents with their adult biological children who were adopted, stands the AD 904 form, a critical document crafted by the State of California's Health and Human Services Agency, specifically under the auspices of the California Department of Social Services (CDSS). This form embodies a straightforward yet profound purpose: to serve as a consent for contact between the parties involved in adoption. The AD 904 form is meticulously designed to ensure that both birth parents and adult adoptees can exercise their voluntary consent for the disclosure of their names and addresses to each other, laying down a foundational step towards re-establishing lost connections. It is crucial that this form is either witnessed by a CDSS or California adoption agency representative or notarized, underscoring the emphasis on the legitimacy and seriousness of consent in these sensitive proceedings. Additionally, the process is delineated with clear instructions, including the necessity for photo identification and the option for either party to rescind their consent at any time, which underscores the dynamic nature of these emotional searches. Further, the form serves as a reminder that while the CDSS facilitates these consents, it does not engage in active search services for birth parents or adoptees, placing the responsibility on the individuals to initiate the process. By capturing essential information and offering options for receiving non-identifying background information, the AD 904 form not only adheres to the legal framework detailed in Family Code Sections 8706 and 8817 but also respects the personal and emotional intricacies inherent in adoption reunification scenarios.
| Question | Answer |
|---|---|
| Form Name | Form Ad 904 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ad904, california consent form pdf, california ad904, california ad 904 form |
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY |
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES |
CONSENT FOR CONTACT
1.Please complete both sides of this form.
2.This form must be witnessed by either a representative of the California Department of Social Services (CDSS) or a California (CA) adoption agency licensed by CDSS, or notarized by a Notary Public.* If the signing of this form is witnessed by a CDSS or adoption agency representative, photo identification of the person signing must be obtained and noted on this form. THIS FORM WILL BE
RETURNED TO YOU IF IT IS NOT WITNESSED OR NOTARIZED
Distribution Instructions:
Original: Agency/Department
Copy: Person Signing
DESIGNATE ONE:
I am the
■Birth Parent
■Adult Adoptee (age 18 or older)
PART A. To be completed by person signing consent
■BIRTH PARENT:
By signing this form, I voluntarily give my consent to the CDSS or licensed adoption agency to disclose my name and address to my adult biological child who was adopted so he/she may contact me.
■ADULT ADOPTEE:
By signing this form, I voluntarily give my consent to the CDSS or licensed adoption agency to disclose my name and address to my birth parent(s) so he/she may contact me.
I understand that the CDSS does not provide search services to locate birth parents or adoptees and that these parties must contact CDSS or the licensed adoption agency to request a Consent for Contact (AD 904) form.
I understand that the birth parent(s) and the adoptee must sign a consent before CDSS or the licensed adoption agency may disclose identifying information and that signing this consent does not necessarily ensure that a contact will be made pursuant to Family Code Section 9204. I understand that the law prohibits CDSS or the licensed adoption agency from soliciting, directly or indirectly, the execution of such a consent.
I understand that I should keep the CDSS or the licensed adoption agency informed of my current name and address.
I understand I have the right to rescind this consent at any time by notifying CDSS or the licensed adoption agency in writing.
NAME (PLEASE PRINT) |
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OTHER NAME(S) BY WHICH I HAVE BEEN KNOWN |
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STREET ADDRESS |
CITY |
STATE |
ZIP CODE |
TELEPHONE NUMBER |
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SIGNATURE |
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DATE |
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PART B. To be completed by a representative of CDSS or a CA licensed adoption agency. If Part B or C is completed, do not complete Part D.
SIGNATURE OF CDSS /ADOPTION AGENCY REPRESENTATIVE |
DATE |
TELEPHONE NUMBER |
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AGENCY/DEPARTMENT NAME |
ADDRESS |
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IDENTIFICATION OF BIRTH PARENT/ADULT ADOPTEE (SPECIFY, I.E., DRIVER’S LICENSE, PASSPORT, ETC.) |
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PART C. |
■ Check if applicable. Notarized signature has been previously submitted to CDSS or a CA licensed adoption agency. |
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PART D. |
To be completed by a Notary Public ONLY IF Part B or C is not completed. |
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***COMPLETED BY Notary Public***
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY
DATE
*Definition of Notary Public: A Notary Public is a public officer authorized by law to certify documents and to confirm your identity. Notaries may be located at most banks and credit unions or listed in the yellow pages of your local phone directory.
AD 904 (7/11) |
SEE REVERSE SIDE |
In order to locate the correct adoption file, please assist us by completing the information below. If you do not know this information, please write “unknown”.
______________________________________________________________________________________________
Adoptee’s name, birth date, city and state of birth
______________________________________________________________________________________________
All names used by birth mother at the time of the adoption (include middle and maiden name(s) and name of birth father.)
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Full names of both adoptive parents
Adoptees:
Birth Parents:
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Please check the box if you also want to receive nonidentifying background information about
your birth parents.
Please check the box if you also want to receive nonidentifying information about the family that
adopted your child.
Refer to Family Code Sections 8706; 8817 for a full description of nonidentifying information.
What Happens to the Consent
The consent may be sent directly to the adoption agency which handled the adoption, if known, or to the Department’s Central Office: Adoptions Support Unit, Department of Social Services, 744 P Street, M.S.
AD 904 (7/11)