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Get Ad 4339 (3/06) - Relinquishment - California Department Of Social ...

This form to an out-of-state agency that has been requested to take the annexed relinquishment. On this day of 20 , the (NAME OF AGENCY) hereby signifies its willingness to accept the annexed relinquishment and to accept said minor child for adoption. By (AUTHORIZED AGENCY OFFICIAL) I, being the mother/father of.

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