Form 53-3

For the medical history report that must also be prepared by the parent, see form 53-23.

For the father’s affidavit of relinquishment of parental rights to a licensed child-placing agency, see form 53-5.

NOTICE: THIS DOCUMENT
CONTAINS SENSITIVE DATA

Father’s Affidavit for Voluntary Relinquishment of Parental Rights

[Nonagency]

State of Texas)

[Name of father] appeared in person before me today and, in the presence of the under­signed credible witnesses, stated under oath:

“My name is [name of father]. I am [years] years of age and reside in [county, state]. I am the [presumed/acknowledged] father of the following child[ren]:

“[Name of child], a [male/female] child born on [date]. The child is [number] [days/months/years] old.

“No person has been appointed or has qualified as guardian of the person[s] or estate[s] of the child[ren].

“The guardian of the [person[s]/estate[s]/person[s] and estate[s]] of the child[ren] is [name], who resides at [address, city, state].

“I [am/am not] presently obligated by court order to make payments for the support of the child[ren].

“A full description, including statement of value, of all property owned or possessed by the child[ren] is as follows: [describe and state value of property for each child; if no property, state “none”].

“The mother of the child[ren] is [name], and she resides in [county, state].

“The parental rights of the child[ren]’s mother have been terminated by her death.

“The parental rights of the child[ren]’s mother have been terminated by court order.

“To the best of my knowledge I do not have Native American Indian ancestry. I am not a registered member of a tribe, nor is any member of my family a registered member of a tribe.

“I have Native American Indian ancestry. [I am/My [relationship] is] a registered mem­ber of the [name of tribe] tribe.

“I designate [name of managing conservator], a prospective adoptive parent, [address], as managing conservator of the child[ren]. I have been informed that my parental rights, pow­ers, duties, and privileges are as follows:

1.the right to have physical possession, to direct the moral and religious training, and to designate the residence of the child[ren];

2.the duty of care, control, protection, and reasonable discipline of the child[ren];

3.the duty to support the child[ren], including providing the child[ren] with clothing, food, shelter, medical and dental care, and education;

4.the duty, except when a guardian of the estate has been appointed, to manage the estate[s] of the child[ren], including the right as an agent of the child to act in relation to the child[ren]’s estate[s] if [the/a] child’s action is required by a state, the United States, or a for­eign government;

5.except as provided by section 264.0111 of the Texas Family Code, the right to the services and earnings of the child[ren];

6.the right to consent to the child[ren]’s marriage, enlistment in the armed forces of the United States, medical and dental care, and psychiatric, psychological, and surgical treat­ment;

7.the right to represent the child[ren] in legal action and to make other decisions of substantial legal significance concerning the child[ren];

8.the right to receive and give receipt for payments for the support of the child[ren] and to hold or disburse funds for the benefit of the child[ren];

9.the right to inherit from and through the child[ren];

10.the right to make decisions concerning the child[ren]’s education; and

11.any other right or duty existing between a parent and child[ren] by virtue of law.

“I freely and voluntarily give and relinquish to [name of managing conservator] all my parental rights and duties.

“I fully understand that a lawsuit [will be promptly/has been] filed in [the [designation] Court of [county] County, Texas/a court of competent jurisdiction] to terminate forever the parent-child relationship between me and the child[ren] named above. I fully understand that the termination suit may or may not be combined with a suit to adopt my child[ren]. I under­stand that either way, once the Court terminates my parental rights, I have no further say con­cerning my child[ren], whether or not my child[ren] [is/are] adopted then or at some later time.

“I know that I have the right to appear personally before the Court, with an attorney of my choice, to testify about my desires with respect to my child[ren]. However, I do not want to go to court in person and choose not to be represented by a lawyer. I want this Affidavit for Voluntary Relinquishment of Parental Rights presented to the Court.

“Because I do not want to testify in person before the Court, I freely and voluntarily waive and give up my right to the issuance, service, and return of citation, notice, and all other process in any suit to terminate my parental rights or in any suit to terminate my parental rights joined with a suit to adopt. I do not want to be informed further about the lawsuit. I spe­cifically agree that a final hearing in the lawsuit may be held at any time without further notice to me. I waive and give up my right to have the official court reporter make a record of the tes­timony in the lawsuit. Furthermore, I do not want to be mailed or given a copy of the judg­ment terminating my parental rights and do not want to be notified of the signing, rendition, or entry of that judgment. I also consent to have any suit affecting the parent-child relationship filed or to be filed with respect to the child[ren] named above be decided by an associate judge appointed under section 201.001 of the Texas Family Code.

“If I am in the armed services of the United States at this time, that fact in no way has interfered with my freedom to make my decision to execute this affidavit, and, insofar as this matter is concerned, I waive all rights, privileges, and exemptions existing or that may hereaf­ter exist in my favor under the Servicemembers Civil Relief Act, including the appointment of counsel to represent me in this case.

“I fully understand that I may not be further informed about the termina­tion suit or about any other hearings or proceedings affecting the child[ren] named in this affidavit.

“Termination of the parent-child relationship is in the best interest of the child[ren]. I understand that I make this termination possible by executing this affidavit.

“I declare that this Affidavit for Voluntary Relinquishment of Paren­tal Rights is and shall be irrevocable for sixty days. I fully understand that, if I change my mind, I cannot force the managing conservator to destroy, revoke, or return this affidavit and that I cannot take back or undo this affidavit in any way during this sixty-day period. I further under­stand that my parental rights probably will have already been ended for all time before this sixty-day period expires. I also understand that, if my parental rights have not been ended within this sixty-day period, this affida­vit shall remain in full force and effect until I revoke it. I fully understand that, at any time until this affidavit is revoked, my parental rights may be terminated for all time.

“This affidavit is revocable only if the revocation is made before the eleventh day after the date the affidavit is executed.

“I understand that, for any revocation to be valid, I must sign a statement before two credible witnesses and a person authorized to take oaths. A copy of the revocation must be delivered to [name and address]. If I know that a termination suit based on this affidavit has been filed, I must file a copy of the revocation with the clerk of the court.

“I have carefully considered alternative plans for my child[ren]’s future and have obtained the advice of whatever family members, friends, or other persons and professionals I feel were necessary to help me make this decision. This decision is very difficult for me to make, and under other circumstances I might have made a different decision. I know that [name], in accepting my child[ren] for adoptive placement and assuming responsibility for my child[ren], is relying on my promise that I will not attempt to reclaim my child[ren]. I declare that I fully understand the meaning of this affidavit of relinquishment and the finality of my action in signing it, and I am signing it freely, voluntarily, and with the firm conviction that this decision is the best available alternative for my child[ren].

“I am signing this affidavit today because I want to sign it and not because [name] or any other person or persons want me to sign it. I am signing this affidavit in the presence of the two undersigned witnesses. I am also signing this affidavit before a notary public, who has asked me under oath whether or not each and every statement in this affidavit is true and cor­rect.

“I realize that I should not sign this Affidavit for Voluntary Relinquish­ment of Parental Rights if there is any thought in my mind that I might someday seek to gain custody of my child[ren]. At the time of the signing of this Affidavit for Voluntary Relinquishment of Parental Rights, I feel that I am physically and emotionally prepared to sign this document. I am not currently under the influence of any substance and/or medication that would affect my ability to execute this affidavit.

“I acknowledge that I am signing this Affidavit for Voluntary Relinquish­ment of Parental Rights more than forty-eight hours after the birth of [the/each] child named in this document.”

   
Affiant

Witnesses at request of affiant:

   
Witness
Printed name:
Address:

   
Witness
Printed name:
Address:

Verification

[Name of father] appeared in person before me today and stated on his oath that he is the affiant, that he has read the foregoing Affidavit for Voluntary Relinquishment of Parental Rights, and that the statements contained in it are within his personal knowledge and are true and correct.

This Affidavit for Voluntary Relinquishment of Parental Rights was signed under oath before me at __________________ __.m. on ______________________________ by the affiant.

   
Notary Public, State of Texas