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, the Georgia Department of Human Resources on , did place the custody and control
(33/37 date)
of a child,
(sex)

,
(birth name)

after adoption as
(adopted name)

born , which child is to be known

(DOB)

in and
(adoptive father)
(adoptive mother)

with the right to adopt said child at such time as might be agreed upon between the aforesaid adoptive parents
and the Georgia Department of Human Resources.
That said child, now in the custody of said adoptive parents, is one and the same as the child whose custody and
control was surrendered to or placed with the Georgia Department of Human Resources under the authority of
either O.C.G.A. 19-8-4 (a) (1) or 19-8-4 (a)(2) and that the provisions of O.C.G.A. 19-8-4 (c)(d)(e)(f)(g)(h)(i)
(j) and 19-8-12 have been complied with or are not applicable;
That it is indicated that adoption by said adoptive parents 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 and . In so much as the
(adoptive father)
(adoptive mother)
Department of Human Resources remains responsible to assure the wellbeing and act in the best interest of the
aforesaid child until a final order of adoption is entered, the Department reserves the right to withdraw this consent
until a final order of adoption is entered.
THIS THE

DAY OF , 20

Director/Designee
County Department of Family and Children Services

SWORN TO AND SUBSCRIBED BEFORE ME THIS THE

ADP 196 Affidavit of Consent to Adoption (Affidavit 1) (Rev. 6-05)

Page 1 of 1

DAY OF , 20

Notary Public
GEORGIA DEPARTMENT OF HUMAN RESOURCES

AFFIDAVIT OF CONSENT TO ADOPTION

(Affidavit 1)

ADP 196 Affidavit of Consent to Adoption (Affidavit 1) (Rev. 6-05)

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