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FORM 578

Form 578 is signed by a mother who is voluntarily surrendering her child for adoption to DHR. A copy of Form 578 must be signed for each child surrendered.

The information on this form provides documentation regarding legal and biological father(s) of a child being surrendered. It is important that the information reflect the marital situation at the time of conception and the time of birth of the child being surrendered.

Each of three (3) copies of Form 578 must contain original signatures and raised notary seal. One copy must be attached to the original copy of the child's Life History, the second copy is for the county file and the third copy is for the signer.

Form 578 must be typed and any corrections must be initialed by all parties. Each section of Form 578 must be completed. The mother must either name the biological father of the child or make a statement as to why the information is unknown or withheld. The information on the child must be exactly the same as it appears on the Form 573 and the mother must sign the Form 578 in exactly the same manner as Form 573. The notary may not be the caseworker who has worked with the family.

Form 578I Mother’s Affidavit - Instructions Page of

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