(3) The petitioner’s child <strong>is</strong>:NameCurrent ResidenceDate <strong>of</strong> BirthSexPlace <strong>of</strong> Birth(4) The person who has custody <strong>of</strong> <strong>the</strong> child <strong>is</strong>:NameAddressCity, <strong>State</strong>, ZipPhoneEmailRelation to child(5) Petitioner <strong>is</strong> asking <strong>the</strong> court to terminate parental rights because:(6) <strong>Th<strong>is</strong></strong> child <strong>is</strong> not a member <strong>of</strong> or eligible for membership in an <strong>In</strong>dian tribe.(7) Petitioner understands that by signing <strong>the</strong> Voluntary Relinqu<strong>is</strong>hment <strong>of</strong> ParentalRights her/h<strong>is</strong> parental rights over th<strong>is</strong> child will be terminated and that s/he willno longer have any rights or obligations <strong>of</strong> a parent to th<strong>is</strong> child from <strong>the</strong> date <strong>the</strong>order terminating petitioner’s parental rights <strong>is</strong> entered and forward.Findings <strong>of</strong> Fact, Conclusions <strong>of</strong> Law and Order Approved Board <strong>of</strong> <strong>Juvenile</strong> <strong>Court</strong> Judges February 13, 2009Rev<strong>is</strong>ed April 1, 2012Page 2 <strong>of</strong> 4
(8) Petitioner understands that <strong>the</strong> parental rights s/he <strong>is</strong> voluntarily relinqu<strong>is</strong>hinginclude, but are not limited to, <strong>the</strong> rights <strong>of</strong> custody, v<strong>is</strong>itation, and any o<strong>the</strong>rcontact with th<strong>is</strong> child, whe<strong>the</strong>r in person, by mail, or any electronic means, andany input regarding dec<strong>is</strong>ions made about th<strong>is</strong> child.(9) Petitioner understands that <strong>the</strong> parental obligations s/he <strong>is</strong> voluntarilyrelinqu<strong>is</strong>hing include, but are not limited to, obligations to provide for <strong>the</strong> care,support, education, and moral training <strong>of</strong> th<strong>is</strong> child.(10) Petitioner understands that s/he must pay any obligation for support <strong>of</strong> th<strong>is</strong> childincurred before <strong>the</strong> date s/he signs <strong>the</strong> Voluntary Relinqu<strong>is</strong>hment <strong>of</strong> ParentalRights.(11) Petitioner understands that termination <strong>of</strong> her/h<strong>is</strong> parental rights does notextingu<strong>is</strong>h th<strong>is</strong> child’s right to inherit from petitioner’s estate upon petitioner’sdeath.(12) Petitioner understands that termination <strong>of</strong> parental rights does not remove fromth<strong>is</strong> child eligibility for benefits from any third person, including, but not limited to,any agency or state, <strong>the</strong> United <strong>State</strong>s or <strong>In</strong>dian tribe.(13) Petitioner <strong>is</strong> not under <strong>the</strong> influence <strong>of</strong> alcohol, prescription or non-prescriptiondrugs, or any substance that might affect her/h<strong>is</strong> thinking or behavior.(14) Petitioner understands that once s/he signs <strong>the</strong> Voluntary Relinqu<strong>is</strong>hment <strong>of</strong>Parental Rights s/he cannnot change her/h<strong>is</strong> mind, that <strong>the</strong> relinqu<strong>is</strong>hmentcannot be changed, and that her/h<strong>is</strong> parental rights and obligations will beterminated forever.The <strong>Court</strong> Concludes That:(15) Petitioner freely and voluntarily signed <strong>the</strong> Voluntary Relinqu<strong>is</strong>hment <strong>of</strong> ParentalRights.(16) The primary purpose for petitioner relinqu<strong>is</strong>hing petitioner’s parental rights <strong>is</strong> notto avoid support obligations for th<strong>is</strong> child.(17) It <strong>is</strong> in <strong>the</strong> best interest <strong>of</strong> <strong>the</strong> child that petitioner’s parental rights be permanentlyterminated.The <strong>Court</strong> Orders That:Findings <strong>of</strong> Fact, Conclusions <strong>of</strong> Law and Order Approved Board <strong>of</strong> <strong>Juvenile</strong> <strong>Court</strong> Judges February 13, 2009Rev<strong>is</strong>ed April 1, 2012Page 3 <strong>of</strong> 4