Form 10-541. Voluntary relinquishment of parental rights and consent to adoption.

STATE OF NEW MEXICO COUNTY OF _______________ ________________ JUDICIAL DISTRICT IN THE CHILDREN’S COURT No. __________ STATE OF NEW MEXICO ex rel. CHILDREN, YOUTH AND FAMILIES DEPARTMENT In the Matter of _____________, a Child, and Concerning ______________________, Respondent(s). VOLUNTARY RELINQUISHMENT OF PARENTAL RIGHTS AND CONSENT TO ADOPTION1, 2 Under Sections 32A-5-17 and 32A-5-21 NMSA 1978, ______________________ (name of Respondent) states: 1. This document is being executed on ______________________ (date), at the ______________________ (indicate judicial district) Judicial District Court, State of New Mexico, before the Honorable ______________________ (name of judge). 2. I, ______________________ (full name of individual relinquishing parental rights), born ______________________ (date of birth), state that I am the ______________________ (indicate relationship to the child, including whether the relationship is biological) of ______________________ (name of child, including any names by which the child has been known), a minor child born on ______________________ (date of birth of child) in ______________________ (place of birth).3 3. This child is not an Indian child as defined by 25 U.S.C. § 1903(4), and this case is not subject to the Indian Child Welfare Act (ICWA). [Or, if ICWA applies to the child: This child is an Indian child as defined by 25 U.S.C. § 1903(4) and is a member of the following tribe(s): ______________________ (list tribal membership(s)).] 4. I understand that the child is in the legal custody of the New Mexico Children, Youth and Families Department, which has responsibility for caring for the child and will retain legal custody until the adoption is final. 5. I understand that this relinquishment is an unconditional relinquishment of my parental rights. [Or, if relinquishment is conditional: I am entering into a conditional relinquishment of my parental rights under the following conditions: ________________________________________.] 6. I do hereby relinquish all my parental rights to the child so that the child may be placed for adoption.4 7. I understand that my child’s right to inherit from me under state law continues until the adoption is final. 8. I have been counseled by ______________________ (name of person providing relinquishment counseling, include agency name and licensure), a certified counselor. This counselor meets the requirements as set forth in Section 32A-5-22 NMSA 1978 and 8.26.3.25 B(1) NMAC. [Or, if the individual relinquishing parental rights has requested waiver of the counseling requirement: I request that the relinquishment counseling requirement be waived because ______________________ (include reasons supporting the request for waiver).] 9. I understand that any informal agreement allowing contact between the child and me will not be enforced by the court. I further understand that a post-adoption contact agreement that has been included in the final adoption decree will be enforced. 10. I understand that this voluntary relinquishment of parental rights and consent to adoption is final and cannot be withdrawn. [Or, if ICWA applies to the child: Under 25 U.S.C. § 1913(c) and 25 C.F.R. § 23.128, I understand that this voluntary relinquishment of parental rights and consent to adoption is final, but may be withdrawn for any reason at any time prior to the entry of a final decree of termination of parental rights or adoption. I understand that to withdraw consent before entry of a final decree of adoption, I must file a written document with the court, testify before the court, or use another method authorized under State law.] 11. I have received or been offered a copy of this relinquishment and consent form. 12. The counseling narrative has been prepared pursuant to the New Mexico Children, Youth and Families Department’s regulations and is attached to this relinquishment as Exhibit A. [Or, if the individual relinquishing parental rights has requested the waiver of the counseling requirement: No counseling narrative is attached because _____________________________ (name of individual relinquishing parental rights) has requested the waiver of the counseling requirement.] 13. I understand that I am not entitled to further notice of the adoption proceedings. 14. The New Mexico Children, Youth and Families Department consents to the relinquishment of parental rights of ______________________ (name of individual relinquishing parental rights). ______________________ (name of individual relinquishing parental rights) ______________________ Date ______________________ Time