We, Mr. ——–, aged — years and Mrs. ———-, aged — years do hereby state as follows :
- We have been married for five years. We have two children, a female child aged four years, and a male child aged one and a half years. We say that with much thought and consideration, we have decided to give up our third child, that is, a female child, born on ——–, in adoption. We are the sole guardians of the child and there is no other lawful guardian for the said child.
- I am working as a newspaper vendor at Dadar and have no permanent shelter. My wife is in long-term hospital care since she is suffering from an advanced stage of tuberculosis which is terminal. My wife and I are finding it very difficult to provide for and look after three children. We have been explained that some kind of support and foster care can be arranged by Family Service Centre, in case we do not wish to abandon this child. However, in the best interests of the child, we have decided, by our own free will, to give up the said baby girl in adoption.
- We say that we are 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 our child and we were specifically told that in case the minor whom we are abandoning, if adopted,we shall have no further contact with the minor.
- We request the authorities not to disclose our full identity or address or whereabout and do not wish to give any information of ourselves because of social reasons.
- We are aware that the Family Service Centre will act in the best interests of the child. However, in unforseeable circumstances, we shall not hold the agency responsible.
- We say that without receiving any monetary and material consideration voluntarily, of our own free will and volition and without inducement, influence, coercion, or fraud and without being under the influence of any person, drink or drug, have handed over our aforementioned child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039, with the authority to Family Service Centre, Bombay, to place the said child in adoption / guardianship with any suitable couple.
- We say that we have abandoned the said child because we are unable to look after, maintain, educate and bring up the said child and have no relative or friend willing to do so. We further say that we were explained and given to understand that we can claim our child within four months from today. We have further been explained that if we do not reclaim our child during this period of four months, the agency will be free to rehabilitate the child at its own discretion either in India or abroad.
- We hereby declare that we have relinquished all our rights and claims to the said child and all reciprocal rights, claims and / or obligations of the parent and child between us and the child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may at 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.
- We request the authorities of Family Service Centre, Bombay, not to disclose our 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-
Relative of natural parents:
Natural mother’s name, signature/thumb impression:
Natural father’s name, signature/thumb impression:
Dated, this day of July 1991: