City, State, Zip 

 
Name 

 
Address 

 
Phone 

 
Email 

 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address.  

I am the 

[  ] Petitioner 
[  ] Attorney for the Petitioner and my Utah Bar number is _________ 

In the Juvenile Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

In the matter of 

____________________________________, 
(Child’s name) 

a minor child 

Petition to Terminate Parental 
Rights Upon Voluntary 
Relinquishment 
(Utah Code 80-4-204) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

(1) 

I am the natural [  ] father [  ] mother of the child named below. 

Name 

Current Residence 

Date of Birth 

Sex 

Petition to Terminate Parental Rights Upon 
Voluntary Relinquishment 
 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised August 27, 2021 

Page 1 of 4 

(2)  My residence is: 

ity, State, Zip 

ddress 

  A

  C

(3)  My child is: 

(5) 

The reason I am asking the court to terminate my parental rights is: 

 

(6) 

[  ]  My child is not a member of or eligible for membership in an Indian tribe. 

(7) 

[  ] 

I am not seeking to terminate my parental rights to avoid my obligation to 
financially support my child. 

I ask the court to: 

(8) 

[  ] 

Schedule a hearing on this petition. 

(9) 

[  ] 

Accept my Voluntary Relinquishment of Parental Rights signed or 
confirmed under oath before a judge or a other person appointed by the 
court for the purpose of taking the relinquishment. 

(10) 

[  ] 

Determine that it is in my child’s best interests for my parental rights to be 
terminated. 

(11) 

[  ] 

Terminate my parental rights based on my voluntary relinquishment. 

Petition to Terminate Parental Rights Upon 
Voluntary Relinquishment 
 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised August 27, 2021 

Page 2 of 4 

(4) 

The person who has custody of the child is: 

Place of Birth 

ame 

ddress 

hone 

mail 

ity, State, Zip 

elation to child 

  N

  A

  C

  P

  E

  R

       

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

    I

 

 
Date 

Petition to Terminate Parental Rights Upon 
Voluntary Relinquishment 
 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised August 27, 2021 

Page 3 of 4 

 

 

 

 

 

 

 

Certificate of Service 

I certify that I filed with the court and am serving a copy of this Petition to Terminate Parental Rights Upon 
Voluntary Relinquishment on the following people. 

Person’s Name 

Method of Service 

Served at this 
Address 

Served on 
this Date 

 

 

 

 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

 

 

 

 

 

Date 

 

Sign here ► 

Typed or printed name 

 

 

Petition to Terminate Parental Rights Upon 
Voluntary Relinquishment 
 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised August 27, 2021 

Page 4 of 4