This form contains 65 fields organized into 25 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Additional Parents Indicator
Additional Parents Indicator Checkbox
Check this box if there are more adopting parents.
Adopting Parent Information
Adopting Parent 1 Name Text
Enter the full name of the first adopting parent.
Adopting Parent 2 Name Text
Enter the full name of the second adopting parent, if applicable.
Adopting Parent Address Text
Provide the street address of the adopting parent(s).
Adopting Parent City Text
Enter the city of residence for the adopting parent(s).
Adopting Parent State Text
Enter the state of residence for the adopting parent(s).
Adopting Parent Zip Code Text
Enter the five-digit zip code of residence for the adopting parent(s).
Adopting Parent Telephone Number Text
Provide the telephone number of the adopting parent(s).
Adopting Parent Lawyer Information Line 1 Text
Provide the first line of the lawyer's name, address, telephone number, e-mail address, and State Bar number, if applicable.
Adopting Parent Lawyer Information Line 2 Text
Continue providing additional lawyer information such as address details, additional contact numbers, or State Bar number, if needed.
More Adopting Parents Checkbox
Check this box if there are more adopting parents and you are providing their information on a separate piece of paper.
Adopting Parent Or Parents
Adopting Parent Name(s) Text
Enter the full name of the adopting parent or parents.
Adopting Parent's Signature
Adopting Parent's Signature Date Date
Enter the date the adopting parent signed this form.
Adopting Parent's Signature Printed Name Text
Enter the adopting parent's printed full name.
California Witness Type
Notary public (the notary acknowledgment is attached) CheckBox
Court clerk CheckBox
Probation officer CheckBox
Qualified court investigator CheckBox
Authorized representative of a licensed adoption agency CheckBox
County welfare department staff member CheckBox
Case Information
Adopting Parent or Parents Text
Enter the full name(s) of the adopting parent or parents.
Case Number Text
Enter the official case number assigned to this filing.
Case Number
Case Number Text
Provide the case number for this form.
Child Information
Child's Name Before Adoption Text
Enter the child's full name as it was recorded before the adoption.
Child's Name After Adoption Text
Enter the child's full name as it will be after the adoption.
Child's Date of Birth Date
Provide the child's complete date of birth.
Child's Age Text
Enter the child's current age in years.
Child's Signature
Child's Signature Date Date
Enter the date the child signs the adoption agreement.
Child's Printed Name Text
Enter the child's full name, to be printed for their signature.
Court Filing Information
Court Name and Address Text
Provide the full name of the court and its street address.
Case Number Text
Enter the official case number assigned by the court.
Execution Method
Executed outside of hearing Checkbox
Check this box if the form was signed outside of a hearing, for a stepparent adoption to confirm parentage where a hearing was not ordered or appearance was waived.
Executed at hearing Checkbox
Check this box if the form was signed at a hearing in front of a judicial officer.
Executed by parent at remote hearing Checkbox
Check this box if the form was signed by the adopting parent or parents either before or during a remote hearing and was acknowledged by the judicial officer.
First Adopting Parent Signature
First Adopting Parent Signature Date Date
Enter the date of the first adopting parent's signature.
First Adopting Parent Signature Name Text
Enter the full name of the first adopting parent for their signature.
First Adopting Parent Signature Details
First Parent Signature Date Date
Provide the date the first adopting parent signed.
First Parent Printed Name Text
Provide the typed or printed name of the first adopting parent.
General
Print this form Button
Save this form Button
Clear this form Button
Judge's Date
Judge's Date Date
Enter the date provided by the Judge or Judicial Officer.
Legal Parent Signature
Legal Parent Signature Date Date
Enter the date the legal parent signed the document.
Legal Parent Printed Name Text
Enter the legal parent's printed name.
More Adopting Parents Indicator
More Adopting Parents Checkbox
Check this box if there are more adopting parents than space provided, and you will attach a separate piece of paper with the required information.
Non-California Witness Type
Non-California Notary public Checkbox
Check this box if the form was signed outside of California in front of a notary public and the notary acknowledgment is attached.
Non-California Other person authorized to perform notarial acts Checkbox
Check this box if the form was signed outside of California in front of another person authorized to perform notarial acts and proof of notarization is attached.
Non-California Authorized representative of adoption agency Checkbox
Check this box if the form was signed outside of California in front of an authorized representative of an adoption agency that is licensed in the state or country where the form was signed.
Second Adopting Parent Signature
Second Adopting Parent Signature Date Date
Enter the date the second adopting parent signed the form.
Second Adopting Parent Printed Name Text
Enter the typed or printed name of the second adopting parent.
Second Adopting Parent Signature Details
Second Adopting Parent Signature Date Date
Enter the date the second adopting parent signed the form.
Second Adopting Parent Name Text
Enter the typed or printed name of the second adopting parent.
Signature Jurisdiction
1. Signed in California Checkbox
Check this box if the form was signed within California.
2. Signed outside of California Checkbox
Check this box if the form was signed outside of California.
Spouse's Consent Signature
Spouse's Consent Date Date
Enter the date the spouse or registered domestic partner is signing the consent form.
Spouse's Printed Name Text
Provide the printed name of the spouse or registered domestic partner.
Third Adopting Parent Signature
Third Adopting Parent Signature Date Date
Provide the date when the third adopting parent signed the form.
Third Adopting Parent Signature Name Text
Enter the full name of the third adopting parent who signed the form.
Tribal Customary Adoption Order Date
Tribal Customary Adoption Order Date Date
Enter the date of the tribal customary adoption order.
Witness Information
Witness County Signed Text
Enter the county where the form was signed by the witness.
Witness State Signed Text
Enter the state where the form was signed by the witness.
Witness Country Signed Text
Enter the country where the form was signed by the witness.
Witness Name Text
Enter the full name of the witness.
Witness Agency Text
Enter the name of the agency the witness works for, if applicable.
Witness Date Signed Date
Enter the date the witness signed the form.