I, ——– aged ——- do hereby state as follows:
- I delivered a child on ——- at ——. The said child is born out of wedlock and has been in my guardianship and custody thereafter.
- I request the authorities not to disclose my full identity or address or whereabouts and do not wish to give any information of the father, or other relatives of the said child, because of social reasons.
- I am the sole guardian of the said child and there is no other lawful guardian or father for the said child.
- I say that I was helped by the authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039 to understand all implications of adoption of my child and I was specifically told that in case the minor whom I am abandoning, if adopted, I shall have no further contact with the minor. I have made this decision of abandoning the minor after due thought and consideration.
- I say that I, without receiving any monetary and material consideration voluntarily of my own free will and volition and without any inducement, influence, coercion or fraud and without being under the influence of any person, drink or drug, have today handed over my aforesaid child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039 with the authority to Family Service Centre, Bombay to place the said child in adoption / guardianship with any suitable people.
- I say that I have abandoned the said child because I am unable to look after, maintain, educate and bring up the child and have no relative, friend willing to do so. I further say that I was explained and given to understand that I can claim my child within three months from today. I have further been explained that if I do not reclaim my child during this period of three months the agency will be free to rehabilitate the child at its own discretion either in India or abroad. I further state that should any untoward event occur with regard to the child when in the agency’s foster care, I shall not hold the agency responsible.
- I hereby declare that I have relinquished all my rights and claims to the said child and all reciprocal rights, claims and/or obligations of the parent and child between me and the said child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may in their discretion place the said child into any good family irrespective of religion, in India /abroad, or transfer the child to any institution for the purpose of adoption/guardianship or any suitable rehabilitation.
- *The sample documents are derived from the records of the Family Service Centre,Bombay.
8. I request the authorities of Family Service Centre, Bombay, not to disclose my name and identity, known to them, to person or persons or authority at any time and under any circumstances.
Read over and explained by me-
Dated this day of 1992:
Natural mother’s name , signature/thumb impression:
Signature.thumb impression of natural mother’s relative: