(a) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-4 shall conform substantially to the following form:

"SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it, you are

surrendering all of your rights to the child identified in this document,

so as to place the child for adoption. Understand that you are signing

this document under oath and that if you knowingly and willfully make a

false statement in this document you will be guilty of the crime of false

swearing. As explained below in paragraph 5, you have the right to revoke

this surrender within four days from the date you sign it.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of parent or guardian) who,

after having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one]

child, born (name of child) on (birthdate of child)

at : (A.M.) (P.M.) [circle one], should receive the benefits and

advantages of a good home, to the end that (she) (he) [circle one] may be

fitted for the requirements of life, consent to this surrender of my

parental rights.

2.

I, the undersigned, (relationship to child) of the

aforesaid child, do hereby surrender my rights to the child to

(name of child-placing agency, out-of-state licensed

agency, or Department of Human Services, as applicable) and promise not to

interfere in the management of the child in any respect whatever; and, in

consideration of the benefits guaranteed by (name of

child-placing agency, out-of-state licensed agency, or Department of Human

Services, as applicable) in providing for the child, I do relinquish all

rights to the child named in this document, it being my wish, intent, and

purpose to relinquish absolutely all parental control over the child.

Furthermore, I hereby agree that the (name of child-placing

agency, out-of-state licensed agency, or Department of Human Services, as

applicable) may seek for the child a legal adoption by such individual or

individuals as may be chosen by the (name of child-placing

agency, out-of-state licensed agency, or Department of Human Services, as

applicable) or its authorized agents, without further notice to me. I do,

furthermore, expressly waive any other notice or service in any of the

legal proceedings for the adoption of the child.

3.

I understand that under Georgia law an agent appointed by the court is

required to conduct an investigation and render a report to the court in

connection with the legal proceeding for the legal adoption of the child,

and I hereby agree to cooperate fully with such agent in the conduct of its

investigation.

4.

I understand that I will receive a copy of this document after the

witness and I have signed it and it has been notarized.

5.

I understand that under Georgia law I have the unconditional right to a

four-day revocation period. I understand I may only revoke this surrender

by giving written notice, delivered in person or mailed by registered mail

or statutory overnight delivery, to (name and address of

child-placing agency, out-of-state licensed agency, or Department of Human

Services, as applicable) within four days from the date of signing this

document. I understand that certified mail cannot be used for mail

delivery of the notice to revoke this surrender. I understand that the

four days will be counted consecutively beginning with the day immediately

following the date I sign this document; provided, however, that, if the

fourth day falls on a Saturday, Sunday, or legal holiday, then the last day

on which this surrender may be revoked will be the next day that is not a

Saturday, Sunday, or legal holiday. I understand that, if I deliver the

notice to revoke this surrender in person, it must be delivered to

(name and address) not later than 5:00 P.M. eastern

standard time or eastern daylight time, whichever is applicable, on the

fourth day. I understand that I CANNOT revoke this surrender after that

time.

6.

I understand that if I am not a resident of this state that I am

agreeing to be subject to the jurisdiction of the courts of Georgia for any

action filed in connection with the adoption of the child. I agree to be

bound by a decree of adoption rendered as a result of this surrender of my

parental rights.

7.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this document and I am signing

it freely and voluntarily.

This day of , .

(Parent or guardian)

Adult witness

Sworn to and subscribed

before me this

day of , .

Notary Public (SEAL)

My commission expires: ."

(b) The notice to revoke a surrender of rights pursuant to subsection (a) of Code Section 19-8-9 shall conform substantially to the following form:

"NOTICE TO REVOKE SURRENDER OF RIGHTS/

FINAL RELEASE FOR ADOPTION

I, the undersigned, executed a (SURRENDER OF RIGHTSINAL RELEASE FOR

ADOPTION) (PRE-BIRTH SURRENDER OF RIGHTSINAL RELEASE FOR ADOPTION) [circle

one] as to the child identified in the surrender of rights document on

(date). My relationship to the (child) (unborn child) [circle

one] is that I am the (mother) (father) (alleged biological father)

(guardian) [circle one].

(Complete this paragraph if the child has been born.) This notice to

revoke my surrender of rights applies to the (female) (male) [circle one]

child born (name of child) on (birthdate of child).

I now wish to exercise my right to revoke my surrender of rights.

I understand that for my revocation of surrender to be effective I must:

A. Deliver the original of this document in person to the address

designated in the surrender of rights document no later than 5:00 P.M.

eastern standard time or eastern daylight time, whichever is applicable,

on the fourth day of the revocation period specified in the surrender of

rights document;

OR

B. Mail the original of this document by registered mail or by

statutory overnight delivery to the address designated in the surrender

of rights document no later than the fourth day of the revocation period

specified in the surrender of rights document.

This day of , .

(Parent, guardian, or alleged biological father)

(Printed name)

Adult witness"

(c) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-5 shall conform substantially to the following form:

"SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it, you are

surrendering all of your rights to the child identified in this document,

so as to place the child for adoption. Understand that you are signing

this document under oath and that if you knowingly and willfully make a

false statement in this document you will be guilty of the crime of false

swearing. As explained below in paragraph 8, you have the right to revoke

this surrender within four days from the date you sign it.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of parent or guardian) who, after

having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one]

child, born (name of child) on (birthdate of

child) at : (A.M.) (P.M.) [circle one], should receive the

benefits and advantages of a good home, to the end that (she) (he) [circle

one] may be fitted for the requirements of life, consent to this surrender

of my parental rights.

2.

I, the undersigned, (relationship to child) of the

aforesaid child, do hereby surrender my rights to the child to

(name, surname not required, of each individual to whom

surrender is made), PROVIDED that each such individual is named as

petitioner in a petition for adoption of the child filed in accordance with

Article 1 of Chapter 8 of Title 19 of the Official Code of Georgia

Annotated within 60 days from the date that I sign this document.

Furthermore, I promise not to interfere in the management of the child in

any respect whatever; and, in consideration of the benefits guaranteed by

(name, surname not required, of each individual to whom

surrender is made) in providing for the child, I do relinquish all rights

to the child named in this document, it being my wish, intent, and purpose

to relinquish absolutely all parental control over the child.

3.

It is also my wish, intent, and purpose that if each such individual

identified in paragraph 2 is not named as petitioner in a petition for

adoption within the 60 day period, other than for justifiable good cause,

or, if said petition for adoption is filed within 60 days but the adoption

proceeding is dismissed with prejudice or otherwise concluded without an

order declaring the child to be the adopted child of each such individual,

then I do hereby surrender my rights to the child as follows:

Indicate your choice by signing ONE of the following statements (you may

choose statement A, B, or C):

A. (Signature) I wish the child returned to me, as

provided by subsection (j) of Code Section 19-8-5, and I expressly

acknowledge that this provision applies only to the limited circumstance

that the child is not adopted by the individual or individuals

designated in this document and further that this provision does not

impair the validity, absolute finality, or totality of this surrender

under any circumstance other than the failure of the designated

individual or individuals to adopt the child and that no other provision

of this surrender impairs the validity, absolute finality, or totality

of this surrender once the four-day revocation period has elapsed;

OR

B. (Signature) I surrender the child to

(name of child-placing agency or out-of-state licensed agency), as

provided in subsection (j) of Code Section 19-8-5, for placement for

adoption. I understand that if the child-placing agency or out-of-state

licensed agency declines to accept the child for placement for adoption,

this surrender will be in favor of the Department of Human Services for

placement for adoption and (name of child-placing agency

or out-of-state licensed agency) or the Department of Human Services may

petition the superior court for custody of the child in accordance with

the terms of this surrender;

OR

C. (Signature) I surrender the child to the Department

of Human Services, as provided by subsection (j) of Code Section 19-8-5,

for placement for adoption; and the Department of Human Services may

petition the superior court for custody of the child in accordance with

the terms of this surrender.

4.

I hereby agree that the child is to be adopted by each individual named

in paragraph 2 or by any other individual as may be chosen by

(name of child-placing agency or out-of-state licensed

agency) or the Department of Human Services and I do expressly waive any

other notice or service in any of the legal proceedings for the adoption of

the child.

5.

I understand that under Georgia law an evaluator is required to conduct

and provide to the court a home study and make recommendations to the court

regarding the qualification of each individual named in paragraph 2 to

adopt the child concerning the circumstances of placement of the child for

adoption.

6.

I understand that under Georgia law an agent appointed by the court is

required to conduct an investigation and render a report to the court in

connection with the legal proceeding for the legal adoption of the child,

and I hereby agree to cooperate fully with such agent in the conduct of its

investigation.

7.

I understand that I will receive a copy of this document after the

witness and I have signed it and it has been notarized.

8.

I understand that under Georgia law I have the unconditional right to a

four-day revocation period. I understand I may only revoke this surrender

by giving written notice, delivered in person or mailed by registered mail

or statutory overnight delivery, to (name and address of

each individual to whom surrender is made or his or her agent) within four

days from the date of signing this document. I understand that certified

mail cannot be used for mail delivery of the notice to revoke this

surrender. I understand that the four days will be counted consecutively

beginning with the day immediately following the date I sign this document;

provided, however, that, if the fourth day falls on a Saturday, Sunday, or

legal holiday, then the last day on which this surrender may be revoked

will be the next day that is not a Saturday, Sunday, or legal holiday. I

understand that, if I deliver the notice to revoke this surrender in

person, it must be delivered to (name and address) not

later than 5:00 P.M. eastern standard time or eastern daylight time,

whichever is applicable, on the fourth day. I understand that I CANNOT

revoke this surrender after that time.

9.

I understand that if I am not a resident of this state that I am

agreeing to be subject to the jurisdiction of the courts of Georgia for any

action filed in connection with the adoption of the child. I agree to be

bound by a decree of adoption rendered as a result of this surrender of my

parental rights.

10.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this document and I am signing

it freely and voluntarily.

This day of , .

(Parent or guardian)

Adult witness

Sworn to and subscribed

before me this

day of , .

Notary Public (SEAL)

My commission expires: ."

(d) The surrender of rights by a biological father who is not a legal father of the child pursuant to paragraph (2) of subsection (e) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

"SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO ALLEGED BIOLOGICAL FATHER:

This is an important legal document and by signing it you are

surrendering all of your rights to the child identified in this document.

Understand that you are signing this document under oath and that if you

knowingly and willfully make a false statement in this document you will be

guilty of the crime of false swearing. As explained below in paragraph 4,

you have the right to revoke this surrender within four days from the date

you sign it.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized to

administer oaths, (name of alleged biological father) who,

after having been sworn, deposes and says as follows:

1.

I, the undersigned, alleged biological father of a (male) (female)

[circle one] child, born (name of child) to

(name of legal mother) on (birthdate of child) at

: (A.M.) (P.M.) [circle one], being mindful that the child should

receive the benefits and advantages of a good home, to the end that (she)

(he) [circle one] may be fitted for the requirements of life, consent to

this surrender of my rights. I, the undersigned, do hereby surrender my

rights to the child. I promise not to interfere in the management of the

child in any respect whatever; and, in consideration of the benefits

provided to the child through adoption, I do relinquish all rights to the

child named in this document, it being my wish, intent, and purpose to

relinquish absolutely all control over the child.

2.

I hereby agree that the child is to be adopted and I do expressly waive

any other notice or service in any of the legal proceedings for the

adoption of the child. I understand that under Georgia law an agent

appointed by the court is required to conduct an investigation and render a

report to the court in connection with the legal proceeding for the legal

adoption of the child, and I hereby agree to cooperate fully with such

agent in the conduct of its investigation.

3.

I understand that I will receive a copy of this document after the

witness and I have signed it and it has been notarized.

4.

I understand that under Georgia law I have the unconditional right to a

four-day revocation period. I understand I may only revoke this surrender

by giving written notice, delivered in person or mailed by registered mail

or statutory overnight delivery, to (name and address of

child-placing agency representative, out-of-state licensed agency

representative, Department of Human Services representative, individual to

whom surrender is made or his or her agent, or petitioner's representative,

as applicable) within four days from the date of signing this document. I

understand that certified mail cannot be used for mail delivery of the

notice to revoke this surrender. I understand that the four days will be

counted consecutively beginning with the day immediately following the date

I sign this document; provided, however, that, if the fourth day falls on a

Saturday, Sunday, or legal holiday, then the last day on which this

surrender may be revoked will be the next day that is not a Saturday,

Sunday, or legal holiday. I understand that, if I deliver the notice to

revoke this surrender in person, it must be delivered to

(name and address) not later than 5:00 P.M. eastern standard time or

eastern daylight time, whichever is applicable, on the fourth day. I

understand that I CANNOT revoke this surrender after that time.

5.

I understand that if I am not a resident of this state that I am

agreeing to be subject to the jurisdiction of the courts of Georgia for any

action filed in connection with the adoption of the child. I agree to be

bound by a decree of adoption rendered as a result of this surrender of my

parental rights.

6.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this document and I am signing

it freely and voluntarily.

This day of , .

(Alleged biological father)

Adult witness

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(e) The surrender of rights by a parent or guardian pursuant to paragraph (1) of subsection (e) of Code Section 19-8-6 or 19-8-7 shall conform substantially to the following form:

"SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO PARENT OR GUARDIAN:

This is an important legal document and by signing it, you are

surrendering all of your rights to the child identified in this document,

so as to place the child for adoption. Understand that you are signing

this document under oath and that if you knowingly and willfully make a

false statement in this document you will be guilty of the crime of false

swearing. As explained below in paragraph 6, you have the right to revoke

this surrender within four days from the date you sign it.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of parent or guardian) who,

after having been sworn, deposes and says as follows:

1.

I, the undersigned, being mindful that my (male) (female) [circle one]

child, born (name of child) on (birthdate

of child) at : (A.M.) (P.M.) [circle one], should receive the

benefits and advantages of a good home, to the end that (she) (he) [circle

one] may be fitted for the requirements of life, consent to this surrender

of my parental rights.

2.

I, the undersigned, (relationship to child) of the

aforesaid child, do hereby surrender my rights to the child to

(name of each individual to whom surrender is made) and

promise not to interfere in the management of the child in any respect

whatever; and, in consideration of the benefits guaranteed by

(name of each individual to whom surrender is made) in

providing for the child, I do relinquish all rights to the child named in

this document, it being my wish, intent, and purpose to relinquish

absolutely all parental control over the child.

3.

I hereby agree that (name of each individual to whom

surrender is made) may initiate legal proceedings for the legal adoption of

the child without further notice to me. I do, furthermore, expressly waive

any other notice or service in any of the legal proceedings for the

adoption of the child.

4.

I understand that under Georgia law an agent may be appointed by the

court to conduct an investigation and render a report to the court in

connection with the legal proceeding for the legal adoption of the child,

and I hereby agree to cooperate fully with such agent in the conduct of its

investigation.

5.

I understand that I will receive a copy of this document after the

witness and I have signed it and it has been notarized.

6.

I understand that under Georgia law I have the unconditional right to a

four-day revocation period. I understand I may only revoke this surrender

by giving written notice, delivered in person or mailed by registered mail

or statutory overnight delivery, to (name and address of

each individual to whom surrender is made or petitioner's representative,

as applicable) within four days from the date of signing this document. I

understand that certified mail cannot be used for mail delivery of the

notice to revoke this surrender. I understand that the four days will be

counted consecutively beginning with the day immediately following the date

I sign this document; provided, however, that, if the fourth day falls on a

Saturday, Sunday, or legal holiday, then the last day on which this

surrender may be revoked will be the next day that is not a Saturday,

Sunday, or legal holiday. I understand that, if I deliver the notice to

revoke my surrender in person, it must be delivered to

(name and address) not later than 5:00 P.M. eastern standard time or

eastern daylight time, whichever is applicable, on the fourth day. I

understand that I CANNOT revoke this surrender after that time.

7.

I understand that if I am not a resident of this state that I am

agreeing to be subject to the jurisdiction of the courts of Georgia for any

action filed in connection with the adoption of the child. I agree to be

bound by a decree of adoption rendered as a result of this surrender of my

parental rights.

8.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this document and I am signing

it freely and voluntarily.

This day of , .

(Parent or guardian)

Adult witness

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(f) The pre-birth surrender of rights by a biological father who is not a legal father of the child pursuant to paragraph (3) of subsection (e) of Code Section 19-8-4, 19-8-5, or 19-8-7 shall conform substantially to the following form:

"PRE-BIRTH SURRENDER OF RIGHTS

FINAL RELEASE FOR ADOPTION

NOTICE TO ALLEGED BIOLOGICAL FATHER:

This is an important legal document and by signing it, you are

surrendering any and all of your rights to the child identified in this

document, so as to place the child for adoption. You have the right to

wait to execute a PRE-BIRTH SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION

after the child is born, but by signing this document, you are electing to

surrender your rights prior to the birth of this child. Understand that

you are signing this document under oath and that if you knowingly and

willfully make a false statement in this document you will be guilty of the

crime of false swearing. As explained below in paragraph 6, you have the

right to revoke this pre-birth surrender within four days from the date you

sign it.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of alleged biological father)

who, after having been sworn, deposes and says as follows:

1.

I, the undersigned, understand that I have been named by , the

biological mother of the child expected to be born in (city)

(county) (state) on or about the day of (month),

(year), as the biological father or possible biological father of her

child. I further understand that the biological mother wishes to place this

child for adoption.

2.

To the best of my knowledge and belief, the child has not been born as

of the date I am signing this pre-birth surrender; however, if in fact the

child has been born, this surrender shall have the same effect as if it

were a surrender executed following the birth of the child.

3.

I understand that by signing this document I am not admitting that I am

the biological father of this child, but if I am, I hereby agree that

adoption is in this child's best interest. I consent to adoption of this

child by any individual chosen by the child's legal mother or by any public

or private agency that places children without further notice to me. I

expressly waive any other notice or service in any of the legal proceedings

for the adoption of the child. I understand that I have the option to wait

until after the child is born to execute a surrender of my rights (with a

corresponding four-day right of revocation) and, further, that by executing

this document I am electing instead to surrender my rights before the

child's birth.

4.

I understand that signing this document does not fully and finally

terminate my rights and responsibilities until an order from a court of

competent jurisdiction terminating my rights or a final order of adoption

is entered. I understand that if the child is not adopted after I sign

this document, legal proceedings can be brought to establish paternity, and

I may become liable for financial obligations related to the birth and

support of this child.

5.

I understand that I will receive a copy of this document after the

witness and I have signed it and it has been notarized.

6.

I understand that under Georgia law I have the unconditional right to a

four-day revocation period. I understand that I may only revoke this

pre-birth surrender by giving written notice, delivered in person or mailed

by registered mail or statutory overnight delivery, to

(name and address of child-placing agency representative, out-of-state

licensed agency representative, Department of Human Services

representative, individual to whom surrender is made or his or her agent,

or petitioner's representative, as applicable) within four days from the

date of signing this document. I understand that certified mail cannot be

used for mail delivery of the notice to revoke this pre-birth surrender. I

understand that the four days will be counted consecutively beginning with

the day immediately following the date I sign this document; provided,

however, that, if the fourth day falls on a Saturday, Sunday, or legal

holiday, then the last day on which this surrender may be revoked will be

the next day that is not a Saturday, Sunday, or legal holiday. I

understand that, if I deliver the notice to revoke this surrender in

person, it must be delivered to (name and address) not

later than 5:00 P.M. eastern standard time or eastern daylight time,

whichever is applicable, on the fourth day. I understand that I CANNOT

revoke this surrender after that time.

7.

If prior to my signing this pre-birth surrender I have registered on

Georgia's putative father registry then, if I do not revoke this surrender

within the time permitted, I waive the notice I would be entitled to

receive pursuant to Code Section 19-8-12 of the Official Code of Georgia

Annotated because of my registration on the putative father registry.

8.

I understand that if I am not a resident of this state that I am

agreeing to be subject to the jurisdiction of the courts of Georgia for any

action filed in connection with the adoption of the child. I agree to be

bound by a decree of adoption rendered as a result of this surrender of my

parental rights.

9.

Furthermore, I hereby certify that I have not been subjected to any

duress or undue pressure in the execution of this document and I am signing

it freely and voluntarily.

This day of , .

(Alleged biological father)

Adult witness

Sworn to and subscribed

before me this day of

, .

Notary public (SEAL)

My commission expires: ."

(g) The acknowledgment of surrender of rights pursuant to subsection (f) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

"ACKNOWLEDGMENT OF SURRENDER

OF RIGHTS

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of parent, guardian, or alleged

biological father) who, after having been sworn, deposes and says as

follows:

(A) That I have read the accompanying (PRE-BIRTH SURRENDER OF

RIGHTS/FINAL RELEASE FOR ADOPTION) (SURRENDER OF RIGHTS/FINAL RELEASE

FOR ADOPTION) [circle one] relating to the child born (name

of child), a (male) (female) [circle one] on (birthdate of

child);

(B) That I understand that this is a full, final, and complete

surrender, release, and termination of all of my rights to the child;

(C) That I have chosen to retain the unconditional right to revoke

the surrender by giving written notice, delivered in person or mailed by

registered mail or statutory overnight delivery, to

(name and address of child-placing agency or its representative,

out-of-state licensed agency or its representative, Department of Human

Services or its representative, individual to whom surrender is made or

his or her agent, or petitioner's representative, as applicable) within

four days from the date of signing the surrender and that after such

four-day revocation period I shall have no right to revoke the

surrender. I understand that certified mail cannot be used for mail

delivery of the notice to revoke the surrender of my rights. I

understand that, if I deliver the notice to revoke my surrender in

person, it must be delivered to (name and address) not

later than 5:00 P.M. eastern standard time or eastern daylight time,

whichever is applicable, on the fourth day. I understand that the four

days will be counted consecutively beginning with the day immediately

following the date I signed the surrender; provided, however, that, if

the fourth day falls on a Saturday, Sunday, or legal holiday, then the

last day on which the surrender may be revoked will be the next day that

is not a Saturday, Sunday, or legal holiday;

(D) That I have read the accompanying surrender of rights and

received a copy thereof;

(E) That any and all questions regarding the effect of such surrender

and its provisions have been satisfactorily explained to me;

(F) That I have been given an opportunity to consult with an attorney

of my choice before signing of the surrender of my rights; and

(G) That the surrender of my rights has been knowingly,

intentionally, freely, and voluntarily made by me.

This day of , .

(Parent, guardian, or alleged biological father)

Adult witness

Sworn to and subscribed

before me this day of

, .

Notary public (SEAL)

My commission expires: ."

(h) The affidavit of a legal mother required by paragraph (1) of subsection (g) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 for the surrender of her rights shall meet the following requirements:

(1) The affidavit shall set forth:

(A) Her name;

(B) Her relationship to the child;

(C) Her age;

(D) Her marital status at the time of conception and of the birth of the child;

(E) The identity and last known address of her spouse or former spouse and whether any such spouse is the biological father of the child;

(F) The identity, last known address, and relationship to the legal mother of the biological father of the child, provided that she shall have the right not to disclose the name and address of the biological father of the child should she so desire;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name and address of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded;

(I) Whether or not the biological father of the child is or was in a branch of the United States armed forces and, if so, provide details as to his military service;

(J) Whether or not the biological mother or any member of her family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native;

(K) Whether or not the biological father of the child or any member of his family is or was an enrolled member of a federally recognized American Indian tribe, is or was a resident of an American Indian reservation, or is or was an Alaskan native; and

(L) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of the child, or the placement or arranging for the placement of the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received; and

(2) The affidavit shall conform substantially to the following form:

"LEGAL MOTHER'S AFFIDAVIT

NOTICE TO LEGAL MOTHER:

This is an important legal document which deals with the child's right

to have his or her biological father's rights properly determined. You

have the right not to disclose the name and address of the biological

father of the child. Understand that you are providing this affidavit

under oath and that if you knowingly and willfully make a false statement

in this affidavit you will be guilty of the crime of false swearing. The

information you provide will be held in strict confidence and will be used

only in connection with the adoption of the child.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, , who, after having been sworn, deposes and

says as follows:

That my name is .

That I am the legal mother of a (male) (female) [circle one] child

born (name of child) in the State of , County of on

(birthdate of child) at : (A.M.) (P.M.) [circle

one]. That I am years of age, having been born in the State of ,

County of on .

That my social security number is .

That my marital status at the time of the conception of the child was

(check the status and complete the appropriate information):

( ) Single, never having been married.

( ) Separated but not legally divorced; the name of my spouse

(was) (is) [circle one] ; my spouse's last known address is

; we were married in the State of , County of

on ; we have been separated since ; we last had sexual

relations on (date); my spouse (is) (is not) [circle one] the

biological father of said child.

( ) Divorced; the name of my former spouse is ; we were

married in the State of , County of on ; we last had

sexual relations on (date); my former spouse's last known

address is ; divorce granted in the State of , County

of on ; my former spouse (is) (is not) [circle one] the

biological father of said child.

( ) Legally married; the name of my spouse (was) (is) [circle

one] ; we were married in the State of , County of on

; and my spouse's last known address is ; my spouse (is)

(is not) [circle one] the biological father of said child.

( ) Married through common-law marriage relationship prior to

January 1, 1997; the name of my spouse (was) (is) [circle one]

; my spouse's last known address is ; our

relationship began in the State of , County of on

; my spouse (is) (is not) [circle one] the biological father

of said child.

( ) Widowed; the name of my deceased spouse was ; we

were married in the State of , County of on ; my

spouse died on in the County of , State of .

That my name and marital status at the time of the birth of the child

was (check the status and complete the appropriate information):

Name

( ) Single, never having been married.

( ) Separated, but not legally divorced; the name of my spouse

(was) (is) [circle one] ; my spouse's last known address is

; we were married in the State of , County of

on ; we have been separated since ; we last had sexual

relations on (date); my spouse (is) (is not) [circle one] the

biological father of said child.

( ) Divorced; the name of my former spouse is ; we were

married in the State of , County of on ; we last

had sexual relations on (date); my spouse's last known address

is ; divorce granted in the State of , County of ;

my former spouse (is) (is not) [circle one] the biological father of

said child.

( ) Legally married; the name of my spouse (was) (is) [circle

one] ; we were married in the State of , County of

on ; my spouse's last known address is ; my spouse (is)

(is not) [circle one] the biological father of said child.

( ) Married through common-law relationship prior to January 1,

1997; the name of my spouse (was) (is) [circle one] ; my

spouse's last known address is ; our relationship began in the

State of , County of on ; my spouse (is) (is not)

[circle one] the biological father of said child.

( ) Widowed; the name of my deceased spouse was ; we were

married in the State of , County of on ; my spouse

died on in the County of , State of ; he (was)

(was not) [circle one] the biological father of said child.

That the name of the biological father of the child is (complete

appropriate response):

Known to me and is ( );

Known to me but I expressly decline to identify him because

; or

Unknown to me because

.

That the last known address of the biological father of the child is

(complete appropriate response):

Known to me and is ;

Known to me but I expressly decline to provide his address because

; or

Unknown to me because

.

That, to the best of my knowledge, I (am) (am not) [circle one] an

enrolled member of a federally recognized American Indian tribe, (am)

(am not) [circle one] a resident of an American Indian reservation, or

(am) (am not) [circle one] an Alaskan native. If so:

(A) The name of my American Indian tribe is .

(B) The percentage of my American Indian blood is percent.

That, to the best of my knowledge, a member of my family (is or was)

(is not or was not) [circle one] an enrolled member of a federally

recognized American Indian tribe, (is or was) (is not or was not)

[circle one] a resident of an American Indian reservation, or (is or

was) (is not or was not) [circle one] an Alaskan native. If so:

(A) The name of the American Indian tribe is .

(B) The percentage of my American Indian blood is percent.

(C) My relatives with American Indian or Alaskan native blood are

.

(D) The name of the American Indian tribe is .

(E) The name of each enrolled member is , and his or her

corresponding registration or identification number is .

That, to the best of my knowledge, the biological father or a member

of his family (is or was) (is not or was not) [circle one] an enrolled

member of a federally recognized American Indian tribe, (is or was) (is

not or was not) [circle one] a resident of an American Indian

reservation, or (is or was) (is not or was not) [circle one] an Alaskan

native. If so:

(A) The name of his American Indian tribe is .

(B) The percentage of his American Indian blood is percent.

(C) His relatives with American Indian or Alaskan native blood are

.

(D) The name of each enrolled member is , and his or her

corresponding registration or identification number is .

That the date of birth of the biological father (is , )

(is not known to me) [circle one].

That the biological father (is) (is not) [circle one] on active duty

in a branch of the United States armed forces. If so:

(A) The branch of his service is (Army) (Navy) (Marine) (Air

Force) (Coast Guard) [circle one].

(B) His rank is .

(C) His duty station is .

If applicable, please provide any additional available

information regarding his military service.

.

That the biological father of the child, whether or not identified in

this document (circle the appropriate phrase):

(Was) (Was not) married to me at the time this child was conceived;

(Was) (Was not) married to me at any time during my pregnancy with

this child;

(Was) (Was not) married to me at the time that this child was born;

(Did) (Did not) marry me after the child was born and recognize

the child as his own;

(Has) (Has not) been determined to be the child's father by a

final paternity order of a court;

(Has) (Has not) legitimated the child by a final court order;

(Has) (Has not) lived with the child;

(Has) (Has not) contributed to its support;

(Has) (Has not) provided for my support during my pregnancy or

hospitalization for the birth of the child; and

(Has) (Has not) provided for my medical care during my pregnancy

or hospitalization for the birth of the child.

That I (have) (have not) [circle one] consented to the appointment of

a temporary guardian for the child. If so, the name of the temporary

guardian is , and the probate court in which the petition

for temporary guardianship was filed is .

That custody of the child has been awarded to (name and

address of custodian) by order of the Court of

County, State of , entered on (date).

That I have received or been promised the following financial

assistance, either directly or indirectly, from whatever source, in

connection with my pregnancy, the birth of the child, and the child's

placement for adoption: .

That I recognize that if I knowingly and willfully make a false

statement in this affidavit I will be guilty of the crime of false

swearing.

(Legal mother)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires ."

(i) The affidavit of an adoptive mother required by paragraph (2) of subsection (g) of Code Section 19-8-4, 19-8-5, 19-8-6, or 19-8-7 for the surrender of her rights shall meet the following requirements:

(1) The affidavit shall set forth:

(A) Her name;

(B) Her relationship to the child;

(C) Her age;

(D) Her marital status;

(E) The name and last known address of any spouse or former spouse at the time the child was adopted and whether any such spouse also adopted the child or is the biological father of the child;

(F) The circumstances surrounding her adoption of the child, including the date the adoption was finalized, the state and county where finalized, and the name and address of the adoption agency, if any;

(G) Whether or not she has consented to the appointment of a temporary guardian for the child and, if so, provide the name of the temporary guardian and the probate court in which the petition for temporary guardianship was filed;

(H) Whether custody of the child has been awarded to another individual and, if so, provide the name of the child's custodian and the court in which custody was awarded; and

(I) All financial assistance received by or promised her either directly or indirectly, from whatever source, in connection with the placement or arranging for the placement of the child for adoption (including the date, amount or value, description, payor, and payee), provided that financial assistance provided directly by her husband, mother, father, sister, brother, aunt, uncle, grandfather, or grandmother need not be detailed and instead she need only state the nature of the assistance received.

(2) The affidavit shall be in substantially the following form:

"ADOPTIVE MOTHER'S AFFIDAVIT

NOTICE TO ADOPTIVE MOTHER:

This is an important legal document which deals with the adopted

child's right to have his or her legal father's rights properly

determined. Understand that you are providing this affidavit under oath

and that if you knowingly and willfully make a false statement in this

affidavit you will be guilty of the crime of false swearing. The

information you provide will be held in strict confidence and will be

used only in connection with the adoption of the child.

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly

authorized to administer oaths, , who, after having been sworn,

deposes and says as follows:

That my name is .

That I am the adoptive mother of a (male) (female) [circle one]

child born (name of child) in the State of , County

of on (birthdate of child) at : (A.M.) (P.M.)

[circle one].

That I am years of age, having been born in the State of

, County of on .

That my social security number is .

That my marital status is (check the status and complete the

appropriate information):

( ) Single, never having been married.

( ) Separated but not legally divorced; the name of my spouse

(was) (is) [circle one] ; my spouse's last known address is

; we were married in the State of , County of

on ; we have been separated since ; we last had sexual

relations on (date); my spouse (did) (did not) [circle one]

also adopt said child; my spouse (is) (is not) [circle one] the

biological father of said child.

( ) Divorced; the name of my former spouse is ; we were

married in the State of , County of on ; we

last had sexual relations on (date); my former spouse's

last known address is ; divorce granted in the State of

, County of on ; my former spouse (did) (did

not) [circle one] also adopt said child; my former spouse (is) (is

not) [circle one] the biological father of said child.

( ) Legally married; the name of my spouse (was) (is) [circle

one] ; we were married in the State of , County of

on ; my spouse's last known address is ; my

spouse (did) (did not) [circle one] also adopt said child; my

spouse (is) (is not) [circle one] the biological father of said

child.

( ) Married through common-law marriage relationship prior to

January 1, 1997; the name of my spouse (was) (is) [circle one]

; my spouse's last known address is ; our

relationship began in the State of , County of on

; my spouse (did) (did not) [circle one] also adopt said

child; my spouse (is) (is not) [circle one] the biological father

of said child.

( ) Widowed; the name of my deceased spouse was ; we

were married in the State of , County of on ;

my spouse died on in the County of , State of ;

he (did) (did not) [circle one] also adopt said child; he (was)

(was not) [circle one] the biological father of said child.

That I adopted the child in the State of , County of .

That the final order of adoption was entered on .

That there (was) (was not) [circle one] an adoption agency

involved in the placement of the child with me for adoption; and if

so its name was , and its address is .

That I (have) (have not) [circle one] consented to the appointment

of a temporary guardian for the child. If so, the name of the

temporary guardian is: , and the probate court in which the

petition for temporary guardianship was filed is .

That custody of the child has been awarded to (name and

address of custodian) by order of the Court of

County, State of , entered on (date).

That I have received or been promised the following financial

assistance, either directly or indirectly, from whatever source, in

connection with the child's placement for adoption: .

That I recognize that if I knowingly and willfully make a false

statement in this affidavit I will be guilty of the crime of false

swearing.

(Adoptive mother)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(j) The affidavit of a child-placing agency, out-of-state licensed agency, or department representative required by subsection (h) of Code Section 19-8-4 shall conform substantially to the following form:

"AFFIDAVIT OF CHILD-PLACING AGENCY,

OUT-OF-STATE LICENSED AGENCY, OR

DEPARTMENT REPRESENTATIVE

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, , who, after having been sworn, deposes and

says as follows:

That I am (position) of (name of department,

child-placing agency, or out-of-state licensed agency).

That prior to the execution of the accompanying SURRENDER OF

RIGHTS/FINAL RELEASE FOR ADOPTION by , releasing and

surrendering all of (his) (her) [circle one] rights in a (male) (female)

[circle one] child born (name of child) on

(birthdate of child) at : (A.M.) (P.M.) [circle one], I

reviewed with and explained to such individual all of the provisions of

the surrender of rights, and particularly the provisions which provide

that the surrender is a full surrender of all rights to the child.

That based on my review and explanation to such individual, it is my

opinion that such individual knowingly, intentionally, freely, and

voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

(Representative)

(Department or agency name)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(k) The affidavit of a petitioner's representative or of the representative of the individual signing the surrender of rights required by subsection (h) of Code Section 19-8-5, 19-8-6, or 19-8-7 shall conform substantially to the following form:

"AFFIDAVIT OF REPRESENTATIVE

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, , who, after having been sworn, deposes and

says as follows:

That my name is .

That my address is .

That prior to the execution of the accompanying SURRENDER OF

RIGHTS/FINAL RELEASE FOR ADOPTION by , releasing and

surrendering all of (his) (her) [circle one] rights in a (male) (female)

[circle one] child born (name of child) on

(birthdate of child) at : (A.M.) (P.M.) [circle one], I

reviewed with and explained to such individual all of the provisions of

the surrender of rights, and particularly the provisions which provide

that the surrender is a full surrender of all rights to the child.

That based on my review and explanation to such individual, it is my

opinion that such individual knowingly, intentionally, freely, and

voluntarily executed the SURRENDER OF RIGHTS/FINAL RELEASE FOR ADOPTION.

(Petitioner's representative or the

representative of the individual

signing the surrender)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(l) The parental consent to a stepparent adoption required by subsection (j) of Code Section 19-8-6 shall conform substantially to the following form:

"PARENTAL CONSENT TO STEPPARENT ADOPTION

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of parent) who, after having been

sworn, deposes and says as follows:

I, the undersigned, hereby consent that my spouse (name of

spouse) adopt my (son) (daughter) [circle one], (name of child),

whose date of birth is , and in so doing I in no way relinquish or

surrender my parental rights to the child. I further acknowledge service of

a copy of the petition for adoption of the child as filed on behalf of my

spouse, and I hereby consent to the granting of the prayers of the petition

for adoption. I also waive all other and further service and notice of any

kind and nature in connection with the proceedings.

This day of , .

(Parent)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(m) The sworn statement executed by the biological mother identifying an alleged biological father of her unborn child authorized and required by subparagraph (e)(3)(E) of Code Section 19-8-4, 19-8-5, or 19-8-7 shall conform substantially to the following form:

"NOTICE TO BIOLOGICAL MOTHER:

This is an important legal document which will enable the individual you

identify as the biological father of your unborn child to sign a pre-birth

surrender of his rights so as to place your child for adoption. Understand

that you are signing this affidavit under oath and that the information you

provide will be held in strict confidence and will be used only in

connection with the adoption of your unborn child.

STATE OF GEORGIA

COUNTY OF

BIOLOGICAL MOTHER'S AFFIDAVIT IDENTIFYING

BIOLOGICAL FATHER OF HER UNBORN CHILD

Personally appeared before me, the undersigned officer duly authorized to

administer oaths, , who, after having been sworn, deposes and says as

follows:

That my name is .

That I am years of age, having been born in the State of ,

County of on .

That my social security number is .

That I am currently pregnant with a (male) (female) (sex unknown)

[circle one] child who is expected to be born on (due date of

child).

That the name of any alleged biological father is , and his last

known address is .

That I execute this affidavit so that any alleged biological father I

have identified above can be asked to sign a pre-birth surrender of his

rights to assist me in placing the child for adoption once the child is

born.

That I recognize that if I knowingly and willfully make a false

statement in this affidavit I will be guilty of the crime of false swearing.

(Biological mother)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."

(n) The affidavit regarding Native American heritage and military service authorized and required by subsection (k) of Code Sections 19-8-4, 19-8-6, and 19-8-7 and subsection (o) of Code Section 19-8-5 shall conform substantially to the following form:

"NOTICE TO BIOLOGICAL OR LEGAL FATHER:

This is an important legal document. Understand that you are providing

this affidavit under oath and that if you knowingly and willfully make a

false statement in this affidavit you will be guilty of the crime of false

swearing.

AFFIDAVIT REGARDING NATIVE AMERICAN HERITAGE

AND MILITARY SERVICE

STATE OF GEORGIA

COUNTY OF

Personally appeared before me, the undersigned officer duly authorized

to administer oaths, (name of affiant) who, after having been

sworn, deposes and says as follows:

1. That my name is .

2. That I am the (biological) (legal) [circle one] father of a (male)

(female) (sex unknown) [circle one] child (born) (yet to be born)

[circle one] in the State of , County of on .

3. That I am years of age, having been born in the State of

, County of on .

4. That my social security number is .

5. That, to the best of my knowledge, I (am) (am not) [circle one] an

enrolled member of a federally recognized American Indian tribe, (am)

(am not) [circle one] a resident of an American Indian reservation, or

(am) (am not) [circle one] an Alaskan native. If so:

A. The name of my American Indian tribe is .

B. My registration or identification number is .

C. The percentage of my American Indian blood is percent.

6. That, to the best of my knowledge, a member of my family (is or

was) (is not or was not) [circle one] an enrolled member of a federally

recognized American Indian tribe, (is or was) (is not or was not)

[circle one] a resident of an American Indian reservation, or (is or

was) (is not or was not) [circle one] an Alaskan native. If so:

A. The name of the American Indian tribe is .

B. The percentage of my American Indian blood is percent.

C. My relatives with American Indian or Alaskan native blood are

.

D. The name of the American Indian tribe is .

E. The name of each enrolled member is , and his or her

corresponding registration or identification number is .

7. That I (am) (am not) [circle one] on active duty in a branch of

the United States armed forces. If so:

A. The branch of my service is (Army) (Navy) (Marine) (Air Force)

(Coast Guard) [circle one].

B. My rank is .

C. My duty station is .

D. Additional information regarding my military service is

.

8. That I have received or been promised the following financial

assistance, either directly or indirectly, from whatever source, in

connection with the birth of the child and the child's placement for

adoption: .

9. That I recognize that if I knowingly and willfully make a false

statement in this affidavit I will be guilty of the crime of false

swearing.

(Biological or legal father)

Sworn to and subscribed

before me this

day of , .

Notary public (SEAL)

My commission expires: ."