The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

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Here is the text we could read:

WRITTEN CONSENT PURSUANT TO M. G. L. c. 210, § 2
[VOLUNTARY AND UNCONDITIONAL SURRENDER]
(type or print - complete in triplicate)

I, as the                                                of                                                             , age           , of

(relationship to child: mother/father)

(name of child)

the                     sex, born in                                                                 , on                                     ,
(place of birth)

(male/female)

(date of birth)

do hereby voluntarily and unconditionally surrender                                                               to the

(name of child)

care and custody of                                                                             for the purpose of adoption or

(agency or person receiving custody)

such other disposition as may be made by a court of competent jurisdiction.  I waive notice of any

legal proceeding affecting the custody, guardianship, adoption or other disposition of

                                                             .
(name of child)

Signature:

(person giving consent)

I UNDERSTAND THAT THIS SURRENDER IS FINAL AND CANNOT BE REVOKED.

On this                day of                                               ,               , before me personally came and

(day)

(month)

(year)

appeared                                                              and in my presence duly executed the foregoing

instrument, and (he, she) acknowledged to me that (he, she) executed the same as (his, her) free

act and deed, fully cognizant of its irrevocability.

Date

State of

Notary Public

County of

witnesses.

 1)

Signed by                                                                 as (his, her) freely executed consent in the

(person giving consent)

presence of each of us, and of each other, who thereafter have hereunto signed our names as

(Witness No. 1 Signature)

(Witness No. 2 Signature)

2)

(Address)

(Address)

Written Consent - Surrender of Parental Rights

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 1
Fields(s): 25
Average fields per page: 25
Reading Level: Grade 10
LIST Grouping(s): FA-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

transaction_page_set_subform__1 was transaction[0].#pageSet[0].Page1[0].UntitledSubform[0].Chld_nm[0] (0.51 conf)
transaction_page_set_subform__2 was transaction[0].#pageSet[0].Page1[0].UntitledSubform[0].Chld_nm[1] (0.36 conf)
transaction_page_set_subform__3 was transaction[0].#pageSet[0].Page1[0].UntitledSubform[0].Chld_nm[2] (0.36 conf)
transaction_page_relationship was transaction[0].Page1[0].Relationship[0] (0.38 conf)
transaction_page_chld_nm__1 was transaction[0].Page1[0].Chld_nm[0] (0.38 conf)
transaction_page_age was transaction[0].Page1[0].Age[0] (0.38 conf)
transaction_page_gender was transaction[0].Page1[0].Gender[0] (0.38 conf)
transaction_page_po_b was transaction[0].Page1[0].POB[0] (0.35 conf)
transaction_page_b was transaction[0].Page1[0].DOB[0] (0.38 conf)
transaction_page_chld_nm__2 was transaction[0].Page1[0].Chld_nm[1] (0.38 conf)
transaction_page_custody was transaction[0].Page1[0].Custody[0] (0.38 conf)
transaction_page_chld_nm__3 was transaction[0].Page1[0].Chld_nm[2] (0.38 conf)
transaction_page_day was transaction[0].Page1[0].Day[0] (0.38 conf)
transaction_page_month was transaction[0].Page1[0].Month[0] (0.38 conf)
transaction_page_year was transaction[0].Page1[0].Year[0] (0.38 conf)
transaction_page_parent_nm was transaction[0].Page1[0].Parent_nm[0] (0.40 conf)
transaction_page_date was transaction[0].Page1[0].Date[0] (0.38 conf)
transaction_page_state was transaction[0].Page1[0].State[0] (0.38 conf)
transaction_page_notary was transaction[0].Page1[0].Notary[0] (0.38 conf)
transaction_page_county was transaction[0].Page1[0].County[0] (0.38 conf)
transaction_page_consent was transaction[0].Page1[0].Consent[0] (0.38 conf)
transaction_witness_address__1 was transaction[0].Page1[0].Witness1Address_Subform[0].Witness1Address1[0] (0.40 conf)
transaction_witness_address__2 was transaction[0].Page1[0].Witness1Address_Subform[0].Witness1Address2[0] (0.40 conf)
transaction_witness_address__3 was transaction[0].Page1[0].Witness2Address_Subform[0].Witness2Address1[0] (0.40 conf)
transaction_witness_address__4 was transaction[0].Page1[0].Witness2Address_Subform[0].Witness2Address2[0] (0.40 conf)

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Written Consent - Surrender of Parental Rights

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02