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TION OF RECEIPT OF CHILD FREEING DOCUMENTS Instructions: Prepare in duplicate; keep copy; send original to California Department of Social Services. If additional space is necessary, use reverse side. AGENCY I. CHILD Name (Last) (First) (Middle) Birthdate (Month Day Year) Gender Birthplace (City Verified State) Yes No AKAs: II. PARENT(S) - NAMES (Include all AKA.s) MOTHER PRESUMED FATHER(S) First Last Birthdate (Month Day Middle First Last Brithdate (Month Year) Da.

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