12
ANNEX TO FORM 3.
Further particulars of applicant or applicants.
Particulars of O.D.
Name in full (Block capitals)
Address
Occupation
Date of Birth
Relationship (if any) to the infant
FORM 4.
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Consent to an adoption order in respect
of an infant named A.B, 0),
[Tule 9.]
Whereas an application is to be made [by C.D./C.D. and E.D.] (2) or [under the serial number
..]
[Whereas the said A.B. (hereinafter called the infant) is not lose than six weeks old, having been born in on the
19......, and is the person to whom the birth certificate (3) now produced and shown to be marked "A" relates] (4) E
I, the undersigned
being (6)
of
Particulars of E.D.
Name in full (Block capitals)
-------་ --
Addresa
Occupation
Date of Birth
Relationship (if any) to the infant .........ktedernekostakin our co*********
Watong
(1) This statement must be worlded by offdavic, to which the statesbient, Moleringe certificate and other documents referred to in the graten should be exhibited.
(2) Enter the first nume)) and surname do shown in the birth certificats referrąd la in paragraph 4, if available; otherwise enter name(a) and surname by which the infant wa known at the time of the application.
121 If the infant has previously been adopted, a certified copy of the entry in the Adopted Children Register should be, witached, and not u certißed copy of the kind entry In the reintern of birtha; and the particulare given in paragraph shonld volate to the pczenit de parents by adoption and col to the natural porent "or" parents.
(0) Where a birth certificate is not attached, enter the pluse (including counter')) of birih if known.
(5) If the lafout is illegitimate, the father's name should not be given in thin entry: but wee parograph 7.
(8). This paragraph should be completail only If the Infant bas « legal gundian other than the father or mother at the infont,
c) If the lafwat is illegitimate, enter the name of any person known to the applicant who has been adjudged by an order to be the potative father of the infant or who kami acknowledged himself to be the father of the Infant and agreed to contribute to bi ar ber
index150.
(a) The names to be entered here for in the following paragraph) are three of the persona Huumed in paragrapho l * and 7, and where the application in mouda by one of two spouses alone) at the spouse of the applicant,
(9) Thi paragraph should be completed with the name of any of the pervóða badakigad in the previous note wha has not wigoífied his or her consent. Son subescciona (1) and (2) of Abation 5 of the Adoption Ordinanca 1905.
(10) This paragraph seed not be completed if the applicant or either of the applicante la a "relative" of the infant as defined by section 2 of the Adoption Ordinance, 1966.
(11) Thle paragraph need not be completed If the applicant or either of the applicants is a "relative"" of the Infant as defined by section 2 of the Adoption Ordinance. 1966. Where It is completal more than one reforce may be mimod if desired.
(2) If the appliant wilshea kis name to be kept confdestial, iomrt serial number obtained in purnaanes of rule 6 of the Supreme Court (Adoption) Kulen, 1968.
the mother (1 of the infant/
the father ( of the infant/
a guardian of the Infant/
a person liable by virtue of any order or agreement to contribute
to the maintenance of the infant/
a person [acting on behalf of a body] having parental rights in
respect of the infant/
the spouse of the said CD,
hereby state as follows:
(1) I understand that the effect of an adoption order is to deprive a parent or guardian of all rights in respect of the maintenance and upbringing of the infant.
(2) I understand that, when the application for an adoption order in respect of the said A.. is heard by the judge, this document may be used as evidence of my consent to the making of the order unless I have notified the court that I no longer consent. (#).
(3) I hereby consent to the making of an adoption order in pursuance of the said application (on condition that the religious persuasion in which the infant is brought up is
1.
Signed at (8)
by the said
(Signature)
on
[who satisfied me that she fully understood the nature of the foregoing statement and was prepared to surrender her child for adoption.] ~(4),
Notes:
Before ma (Signature)
(Address)
(Description) (6)
--་ ------
(1) Insert numa es known to the consenting party..
(2) Where the name of applicant is not known to the consenting party, and number ku been ablaimed for the application under rule 5 of the Supreme Court (Adoption) Bules, 1966, complete the entry contained in the second seduce bracketa.