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

In the Juvenile Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

____________________________________, 
(Child’s name) 

_______________________________ 
Case Number 

Voluntary Relinquishment of 
Parental Rights 

_______________________________ 
Judge 

Being first duly sworn, and while under oath, I say as follows: 

(1) 

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

 
Name 
 
Address 
 
City, State, Zip 
 
Phone 

 
Email 

 

In the matter of 

a minor child 

ity, State, Zip 

ddress 

  A

  C

(2)  My residence is: 

 

 

Voluntary Relinquishment of Parental Rights 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised December 17, 2019 

Page 1 of 4 

(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. 

(8) 

[  ]  By my signature below, I voluntarily relinquish my parental rights to my child 

and consent to the court terminating my parental rights. 

Voluntary Relinquishment of Parental Rights 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised December 17, 2019 

Page 2 of 4 

 

ame 

ddress 

hone 

mail 

ity, State, Zip 

elation to child 

  N

  A

  C

  P

  E

  R

         

(3)  My child is: 

Name 

Date of Birth 

Sex 

Place of Birth 

(4) 

The person who has custody of the child is: 

Current Residence 

(9) 

[  ] 

It is in my child’s best interest that my parental rights be terminated. 

(10) 

[  ] 

I understand that by signing this document my parental rights and 
obligations over my child will be terminated. I understand that I will no longer 
have any rights or obligations of a parent to my child from the date the order 
is entered and forward. 

(11) 

[  ] 

I understand that the parental rights I am voluntarily relinquishing include, 
but are not limited to, the rights of custody, visitation, and any other contact 
with my child, whether in person, by mail, or any electronic means, and any 
input regarding decisions made about my child. 

(12) 

[  ] 

I understand that the parental obligations that I am voluntarily relinquishing 
include, but are not limited to, obligations to provide for the care, support, 
education, and moral training of my child. 

(13) 

[  ] 

I understand that I must pay any obligation for support of my child incurred 
before the date I sign this document. 

(14) 

[  ] 

I understand that termination of my parental rights does not extinguish my 
child’s right to inherit from my estate upon my death.  

(15) 

[  ] 

I understand that termination of my parental rights does not remove from my 
child eligibility for benefits from any third person, including, but not limited to, 
any agency or state, the United States or Indian tribe. 

(16) 

[  ] 

I am not under the influence of alcohol, prescription or non-prescription 
drugs, or any substance that might affect my thinking or behavior. 

(17) 

[  ] 

I understand that once I sign this document I may not change my mind, that 
the consent cannot be changed, and that my parental rights and obligations 
will be terminated forever. 

(18) 

[  ] 

I have read this document. I understand that by signing it I will 
permanently relinquish all my rights and obligations as a parent to my 
child. Knowing this, I am signing this document freely and voluntarily, 
of my own choice, without any pressure, coercion, undue influence, or 
promises having been made by any person for any purpose. 

 

Signature ► 

Printed name 

 

 

Voluntary Relinquishment of Parental Rights 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised December 17, 2019 

Page 3 of 4 

Date 

 

The following to be completed by the judge or other person appointed by the judge who administers the 
oath and witnesses the voluntary relinquishment. 

(19)  Petitioner signed this Voluntary Relinquishment of Parental Rights under oath 
before me on __________________________ (date). Petitioner’s identity was 
proven to me in the following way:  

   

(20)  The petitioner was placed under oath before questions were asked of the 
petitioner. After being sworn and while under oath, petitioner stated that: 

  S/he had read this document, fully understood its contents, and that the 
contents were true and based on petitioner’s own personal knowledge. 

  S/he understood that by signing this document s/he relinquished all parental 

rights and obligations over this child.  

  S/he understood that once s/he signed this document s/he could not change 

her/his mind, that the consent could be not changed, and that her/his 
parental rights and obligations would be terminated forever. 

  S/he was signing this document freely and voluntarily, of her/his own choice, 

without any pressure, coercion, or promises having been made by any 
person for any purpose. 

(21)  Petitioner then signed the document in my presence. To the best of my 

information and belief, petitioner has read and understands this document and 
has signed it freely and voluntarily. 

Date 

 

Signature ► 
Printed name 

[  ] Judge 
[  ] Person appointed by the judge for the purpose of 
taking the relinquishment  

 

 

 

 

Voluntary Relinquishment of Parental Rights 

Approved Board of Juvenile Court Judges February 13, 2009 
Revised December 17, 2019 

Page 4 of 4