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GARY, TILL, BURLINGHAM & LYNCH
STEVEN R. BURLINGHAM, SB# 88544 FILED
Superior Court of California
5330 Madison Avenue, Suite F County of Placer
Sacramento, California 95841
Telephone: (916) 332-8122 FEB 2.0 2018
Facsimile: (916) 332-8153 Jake Chattese
Email: Steveb@gtblaw.com Executive Officpe& Clerk
KA za, Deputy
Attorney for JOSEPH MONTANEZ and
JESSENIA RIVERA-HINOJOS Es
SUPERIOR COURT OF CALIFORNIA
COUNTY OF PLACER
JOSEPH E. MONTANEZ and CASE NO. SCV0040741
JESSENIA RIVERA-HINOJOS, DECLARATION OF STEVEN R.
BURLINGHAM RE: EXHIBIT
Petitioners COMPILATION IN SUPPORT OF
PETITION FOR ALTERNATIVE WRIT
vs.
THE FAMILY NETWORK, INC.
Respondent Date: 2/20/2018
Time: 8:00 a.m.
BILLY DeVORE and LISA GRIJALVA, Dept: 42
Real Parties in Interest
I, Steven R. Burlingham, declare:
1. I am an attorney at law, duly admitted to practice before
all of the Courts of the State of California and the attorney of
record for Petitioners herein.
a Attached are the true and correct copies of the following
Exhibits which are referenced as attachments in the Verified Writ of
Possession, the Petitioner’s Declaration or Points and Authorities
=|
and other documents filed herein.
DY
A. Relinquishment of Joseph Montanez;
WO
fF
B. Relinquishment of Jessenia Rivera-Hinojos;
C's January 30, 2018 Request for Rescission of
OO
Relinguishment (form 508) by Joseph Montanez;
ON
D. January 30, 2018 Request for Rescission of
Relinquishment (form 508) by Jessenia Rivera-Hinojos;
Oo
Co
E-1 January 29, 2018 Initial Request to Rescind by Joseph
S=
=|
Montanez; and
NY
=
E-2 January 29, 2018 Initial Request to Rescind by
Ss
W
Jessenia Rivera-Hinojos.
FPF
eo
iP February 5, 2018 letter to The Family Network.
OO
=
DD
G. Verified Petition for Writ of Mandate (Sacramento
A= |=
County) without Exhibits filed February 10, 2018 with
WAN
A
proofs of service showing February 12, 2018 service.
O
A
H. February 14, 2018 Amended Request for Rescission of
DOD
NH
Relinquishment (form 508) by Joseph Montanez.
PNM
F
I. February 14, 2018 Amended Request for Rescission of
NY
NM
WwW
Relinquishment (form 508) by Jessenia Rivera-Hinojos.
PD
Ff
NM
oD. February 14, 2018 Letter from the Family Network
oO
NM
denying Petitioners’ Request to Rescind.
OD
PO
K. 22 California Code of Regulations §35169, 35170.
PR
on
Nh
L. Copy of Verified Petition for Writ of Mandate;
=
M. Copy of Verified Complaint for Rescission of
NY
Relinquishment.
WO
I declare under penalty of perjury under the laws of the State
&
of California that the foregoing is true and correct.
On
Executed this 19% day of February, 2018, Sacramento,
ON
California.
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oO
oo
“Sierra, R. Burlinghamy Attorney
=
for Petitioners~-
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EXHIBIT “A”
OF
STATE CALIFORNIA AND
- HEALTH HUMAN AGENCY
SERVICES CALIFORNIA SERVICES
OF SOCIAL
DEPARTMENT
RELINQUISHMENT
In orOut-of-County
(BirthMother/Biological Father/Presumed Father inCalifornia)
beforesending thisformtoan out-of-countyagency thathas been
Complete thissection
requestedto taketheannexed hment.
ralinquis
onthis day of Janay 20 8,
the
(NAME-OF
AGENCY}
to
willingness acceptthe annexed relinquishmentandto acceptsaid minorchildforadoption.
_hereby its
signifies
By (AUTHORIZED
AGENCY OFFICIAL)
I ca -Hinni themother/fatherof MilesRivera ,aminor Maje_ child,
(NAMEOFPARENT) OF
(NAME CHILD) (GENDER)
in
_. Sacramento California
bom on 12/27/2017 ( STATE)
(DATE) , (cry)
relinquishand surrenderthechildforadoptionto_TheFamily Inc.
Network,
do hereby (NAMEOF AGENCY)
CA 95678 ( 916 ) 480-1101
126 Grove Street,Roseville, NUMBER)
(TELEPHONE
{AGENCYADDRESS)
by theCaliforniaDepartment of SocialServicesor authorizedby Welfare and Code
Institutions
an organizationlicensed
46130 tofindhomes for and
children to placechildreninhomes foradoption.
[] | amnot naming theprospectiveadoptive for
parent(s) my child.
{fr | amnaming the person(s)
following as the adoptive
prospective parent(s):
BillyDeVore and lisa Grijalva
{FULL
NAME(S)
OF PROSPECTIVE
ADOPTIVE
PARENT(S))
isnot placed inthe home ofthe named person(s)ormy childisremoved from thehome beforethe
ifmy child the
adoption iscompleted,the agency willnotifyme. | have
wili 30 days fromthe date ofthe noticetorescind
take
relinquishment, no action orselectanother placement formy child.If |do notrescind therelinquishment
withinthe30-day period,theagency may placethechildina home that theagency selects,
thatwhen thisrelinquishmentisfiledwithand acknowledged by the Department
California of Social
|fullyunderstand
Services, my
all to
rights thecustody, servicesand eamings child
phthe and forthe
any responsibility careand supportof
thechild be
will jerminated. AY; ‘
‘—tf_ f “Tf 5 oe
Z f~ cS £1 Zi ie rH" c
tis/
(DATE} GHPASENT)
(SIGNATURE
The foregoingrelinquishmentwas signed on py Jessenia Rivera-Hinogjos inthe presenceof:
(ATED {NAMEOFPARENT)
if
Patcicia, Stan e\& (Are:
¢ = —_
Joseph Montane
)
(NAMEOFWITNESS)
=. OZZZ MELE
STATE OF CALIFORNIA A
COUNTY OF 4 x fAMEYV df me
On this day of A A as, ,20 18 me,
, before | uke Wj eonard MSW A
\ {NAMEOF AGENCY
AUTHORIZED OFFICIAL)
an authorized of
officialthe The Family Network, inc an
NAMEOFAGENC
organizationlicensed by theCaliforniaDepartment ofSocial Servicesor @ thorized by Welfare and Code
Institutions
Section 16130 to find homes for children and to place children in homes for adoption, personally
appeared_jessenia Rivera-Hingjas known to ms tobe the personwhose names scribedtothe
PARENT)
(NAME OF
withininstrumentand acknowledged to me thathe/she e
PRE OF
a’
RRS AR
Sociai Worker
AD$01
{TITLE}
(ENGYSP) {6/14) AD
AND
AD 503
- REPLACES 021
= ?
EXHIBIT A
DEPARTMENT
CALIFORNIA OFSOCIALSERVICES
OF
STATE ANO
- HEALTH
CALIFORNIA HUMAN AGENCY
SERVICINS
STATEMENT OF UNDERSTANDING
AGENCY ADOPTIONS PROGRAM
the child to the adoption agency so the
a child means permanently giving
Relinquishing You permanently give the child tothe
choose other parent(s) toadopt the child.
agency can g and the relinquishment
signing this Statement of Unde rstandin
adoption agency by these documents
any rights as a parent toyour child once
document. You willno longer have
CaliforniaDepartment ofSocial Services.
been filedwith and acknowledged by the
have
of the child,you should be aware thai
thought to be a biological/presumed father
Ifyou are the child even ifyou deny
legal rightsand responsibilitiestoward
under the law you have tophysical custody
to took forlegalcounsel toobtain the right
paternity.You also have a right help you.
child,there are services availableto
child. you
If want to be a parent tothe
of the
decision. You should know allthe
childto the adoption agency is avery important
Giving your e you make your ion.
decis
itsadvantages and disadvantages befor
factsabout and
it weigh
To Complete The Statement Of Understanding:
Instructions
OF UNDERSTANDING AND THE RELINQUISHMENT
BEFORE YOU SIGN THIS STATEMENT TO
WITH YOUR SOCIAL WORKER. BE SURE
DOCUMENT, READ BOTH VERY CAREFULLY
ABOUT ANYTHING YOU DO NOT UNDERSTAND.
ASK QUESTIONS
carefullythought about giving your childto the
Statement of Understanding only afteryou have
1. Complete this by prospective adoptive (s)
parent
are sure you want your child adopted and raised
adoption agency and you
selected by the on
adopti agency.
If youdo not understand a statement, ask your social
each ofthe statements inthisdocument very carefully.
2. Read
worker to explain you
it to untilyou do understand.
your in
initials the box next tothe number ofthatstatement.
if youunderstand and agree with a statement, put
3.
your social worker's explanation, do not the
initial
agree, or if youdo not understand a staternentafter
4. If youdo not
box. Ask formore help and time in making your decision.
Two witnesses must be present when you sign your
all
initialed the boxes, sign your name at theend.
5. If youhave ifthisform is signed outside of
theirnames afteryours. (Witnesses are not necessary
name and they willsign
California).
and the relinquishment document once ithas been
6. You willreceive a copy of thisStatement of Understanding
compieted.
must be used with one of the following forms:
This form
501, AD 501A, AD 504, AD 583, AD 584, or AD 4339.
AD
P. .
Father
Bislogica’Presumed who
a Child
of Detained,
Is Not Court
a Juvenile age 1 of 6
AD 885 ora
Mother
(3/14)
Ward
the ofa Legal (This
Guardian. AD
replaces
form 4338)
Care,
in Out-ol-home
Depentient or
EXHIBIT A
OF
DEPARTMENT
CALIFORNIA SERVICES
SOCIAL
OF
STATE AND
~ HEALTH
CALIFORNIA HUMAN AGENCY
SERVICES
STATEMENT OF UNDERSTANDING
of a Child Who Is Not Detained, a Juvenile Court
Mother or a Biological/Presumed Father
Care, or the Ward of a Legal Guar dian
Dependent in Out-of-home
Date ofBirth 12/27/2017
Name ofChild Miles Rivera
tohelp me in the relinquishment process and the adoption
1 iunderstand |have the rightto look fora lawyer
&
can refer me to publiclegal help inmy community.
agency
Ba
isto me
tell about itsadoption planformy child.
|understand the agency
foradoption toother professional people, my family
|may talkabout my plan to give up my child
|understand
and friends.
and the relinquishment document, |shall no longer be
4. |understand if|sign thisStatement ofUnderstanding Department of
with and acknow ledged by the ia
Californ
e
my child'slegalparent once these documents arefiled
Social Services. This means:
be responsible forthe care ofmy child;and
A. {shall no longer
to the custody,services or earnings of my child.
B. {shallno longer have any right
there are other places the agency can referme to that
|understand if|am not sure | want to giveup my child,
2S
withfamily,health, money and other problems.
could help me
giving my childtothe adoption agency.
6. [understand that bysigning the relinquishment | am
PS
adoptive parent(s), |am givingup the rightto
If|sign a relinquishment thatdoes not name the prospective
A. about who adopts my child be
will made by
prospective adoptive s)
parent( and the finaldecision
select the
the adoption agency.
the prospective adoptive parent(s)for my child.
C iam not naming
adoptive parent(s), |am giving my child to the
B. If| sign a relinquishment that names the prospective
with the person(s) named on the relinquishment
adoption agency which intends to place my child
document.
followingperson(s) as the prospective adoptive parent(s):
Sree 1am naming the
BillyDeVore and Lisa Grijaiva
person(s) or my childis removed from the home before
Ifmy childisnot placed inthe home of thenamed
the adoption iscompleted:
return receipt requested, within 72 hours of the
The agency: willsend me a notice by certifiedmail,
(1) my childfram the home. |must
not toplace my childforadoption orthe decision to remove
decision such a notice.
keep the agency informed ofmy address if want
| toreoeive
days from thedate the notice was mailed tome to either:
(2) |shalihave 30
rescind the relinquishment if| deliver,or have
a. Rescind the relinguishment. The agency will
a writtenrequest to rescind the relinquishment tothe agency
delivered by mail or othermeans,
beforethe end ofthe 30-day period,or
the 30-day period, |shall lose my rightto rescind the
b. Take no action.If| take no-action during
agency willselectadoptive parent(s) for my child,or
relinquishment and the
child. during
ff, the 30-day period, |select another person(s)
c. Select another placement formy
| shallrescindthe relinqu
initial ishment and complete a new
withwhom my childis tobe placed,
the person(s) withwhom | then wish theagency fo place my
relinquishment document ing
identify
child.
Who
of a Child Is Not Detained, Court
a Juvenile
AD885 Mother
(3/14) ora Father
Biological/Presumed Page 2 of6
Ward
or the of a Legal (This
Guardian. AD
replaces
form 4338)
Care,
in Out-ol-nome
Dependent
EXHIBIT A
parent(s) and the birth relatives,including the birthparents, may
fu 7. |understand that the prospective adoptive
continuing corttactbetween the birthrelatives,including
enter into an enforceable writtenagreement to permit
the birthparents, and the child the
if court approves.
agency, |may place my child foradoption with
if| decide not to give my childto the adoption
ae 8. |understand s).
parent( This iscalled an
only to an adoption of my child by ese
this/th
parent(s) | find myself and agree
Independent Adoption.
granted incourt, allinheritance rights from any blood relatives
§S 9. |understand aftermy child'sadoption has been
willor in a trustwhich specificallyincludesmy child. My
willend unless they have made arrangemenis intheir
inheritfrem his/her prospective adoptive parent(s).
chiidwiltlegally
and the relinquishment document, | can take them back
aX 10. |understand If|sign thisStatement of Understanding
or before ithas been filedwith and acknowledged by
during any holding period referredto inNumber 18 below
|also signed a “Waive r of Right To Revoke
Department of Social Services, unless
the California the relinquishment is
If|signed a Waiver of Right To Revoke Relinquishment,
Relinquishment” (AD 929A). Section where
next s
busines day as noted on the Waiver inthe
irrevocable immediately or atthe close ofthe
unless the waiver isvoid or the relinquishment is
“Birth parent must one
initial of the following statements:”
rescinded.
must return my child tome within three working days
A. Under normal circumstances the adoption agency
should ittake more than seven calendar days.
and in no case
parent continue
will unless taken away by other legalaction.
B. The rightsand responsibilitiesas my child's
to me would hurt or otherwise harm my child, the
C. the adoption agency believes returning my child
child ive
protect services agency. The adoption
agency willmake an immediate referralto the county’s
agency willletme know inwritingifthey do this.
Social Services has filedand acknowledged my signed
| understand once the California Department of
ik 11.
relinquishment itisfinal,and
returned to me unless the adoption agency agrees or
A. |cannot stop the relinquishment and have my child
on the relinquishment and my chiidisnot placed
the prospective adoptive parent(s) is/arenamed
unless is completed.
or my child isremove d from thehome before the adoption
inthe named home
agency willinform me inwriting ofthe reason(s) for
B. Ifthe adoption agency does not agree, the adoption
not returning my child.
the rightsand responsibilitiesas my child'sparent will
C. tfthe adoption agency agrees to returnmy child,
continue unless taken away by other legalaction.
itwillnormally take three working days and inno case
D. ifthe adoption agency agrees toreturn my child,
can ittake more than seven calendar days.
or the subject of a petition forjuvenile court
| understand that if the child isa juvenile court dependent
our 12. e
juvenil court,the child'slawyer, and
agency must provide written tion
notifica to the
the
jurisdiction, adoption
ifany, ofthe relinquishment withinfivecourt days.
my lawyer,
agency must answer my questions about his/her
before my child’islegally adopted, the adoption
mr 43. understand
{| tion
informa about the
any future time,the agency must give me ailknown
situation. If|ask for information at
my child has been placed foradoption, the approximate date
status of my child’sadoption, including whether
was not completed or was vacated forany reason, whether
the adoption was completed and, ifthe adoption
adoptive placement ofmy childisagain being considered.
of my address if|want to know when my child
{understand | must keep the adoption agency informed
A.
in an adoptive home and when my child was legally adopted.
was placed
Pp 30f6
Who
of 3 Chiid is Not Court
a Juvenile
Detained,
885 Mother
{3/14} or Father
2 Biologicali/Presumed age 30
AD form
(This AD
replaces 4338)
of
Care,
in Out-ol-home theWardofa Guardian.
Legal
Dependent
EXHIBIT A
parent(s) and the birth relatives,Including the birthparents, may
iu 7. \ understand that the prospective adoptive
continuing contact between the birth ,
relatives g
includin
enter intoan enforceable writtenagreement to permit
the birthparents, and the child the
if court approves.
agency, |may place my child foradoption with
if| decide not te give my child tothe adoption
a 8. |understand parent(s). This is called an
and agree only to an adoption of my childby this/these
parent(s) | findmyself
Independent Adoption.
granted incourt, allinheritance rightsfrom any biood relatives
g8 9. |understand aftermy child'sadoption has been
willor in atrust which specificallyincludes my child. My
Preview
GARY, TILL, BURLINGHAM & LYNCH STEVEN R. BURLINGHAM, SB# 88544 FILED Superior Court of California 5330 Madison Avenue, Suite F County of Placer Sacramento, California 95841 Telephone: (916) 332-8122 FEB 2.0 2018 Facsimile: (916) 332-8153 Jake Chattese Email: Steveb@gtblaw.com Executive Officpe& Clerk KA za, Deputy Attorney for JOSEPH MONTANEZ and JESSENIA RIVERA-HINOJOS Es SUPERIOR COURT OF CALIFORNIA COUNTY OF PLACER JOSEPH E. MONTANEZ and CASE NO. SCV0040741 JESSENIA RIVERA-HINOJOS, DECLARATION OF STEVEN R. BURLINGHAM RE: EXHIBIT Petitioners COMPILATION IN SUPPORT OF PETITION FOR ALTERNATIVE WRIT vs. THE FAMILY NETWORK, INC. Respondent Date: 2/20/2018 Time: 8:00 a.m. BILLY DeVORE and LISA GRIJALVA, Dept: 42 Real Parties in Interest I, Steven R. Burlingham, declare: 1. I am an attorney at law, duly admitted to practice before all of the Courts of the State of California and the attorney of record for Petitioners herein. a Attached are the true and correct copies of the following Exhibits which are referenced as attachments in the Verified Writ of Possession, the Petitioner’s Declaration or Points and Authorities =| and other documents filed herein. DY A. Relinquishment of Joseph Montanez; WO fF B. Relinquishment of Jessenia Rivera-Hinojos; C's January 30, 2018 Request for Rescission of OO Relinguishment (form 508) by Joseph Montanez; ON D. January 30, 2018 Request for Rescission of Relinquishment (form 508) by Jessenia Rivera-Hinojos; Oo Co E-1 January 29, 2018 Initial Request to Rescind by Joseph S= =| Montanez; and NY = E-2 January 29, 2018 Initial Request to Rescind by Ss W Jessenia Rivera-Hinojos. FPF eo iP February 5, 2018 letter to The Family Network. OO = DD G. Verified Petition for Writ of Mandate (Sacramento A= |= County) without Exhibits filed February 10, 2018 with WAN A proofs of service showing February 12, 2018 service. O A H. February 14, 2018 Amended Request for Rescission of DOD NH Relinquishment (form 508) by Joseph Montanez. PNM F I. February 14, 2018 Amended Request for Rescission of NY NM WwW Relinquishment (form 508) by Jessenia Rivera-Hinojos. PD Ff NM oD. February 14, 2018 Letter from the Family Network oO NM denying Petitioners’ Request to Rescind. OD PO K. 22 California Code of Regulations §35169, 35170. PR on Nh L. Copy of Verified Petition for Writ of Mandate; = M. Copy of Verified Complaint for Rescission of NY Relinquishment. WO I declare under penalty of perjury under the laws of the State & of California that the foregoing is true and correct. On Executed this 19% day of February, 2018, Sacramento, ON California. y 7m oO oo “Sierra, R. Burlinghamy Attorney = for Petitioners~- | Sa NY | W FR BSB BP a DW BSB | DN SB OO FP CO ND FF ND NYO PHP WH PHP BRB PH PR Dm PR PR on NM EXHIBIT “A” OF STATE CALIFORNIA AND - HEALTH HUMAN AGENCY SERVICES CALIFORNIA SERVICES OF SOCIAL DEPARTMENT RELINQUISHMENT In orOut-of-County (BirthMother/Biological Father/Presumed Father inCalifornia) beforesending thisformtoan out-of-countyagency thathas been Complete thissection requestedto taketheannexed hment. ralinquis onthis day of Janay 20 8, the (NAME-OF AGENCY} to willingness acceptthe annexed relinquishmentandto acceptsaid minorchildforadoption. _hereby its signifies By (AUTHORIZED AGENCY OFFICIAL) I ca -Hinni themother/fatherof MilesRivera ,aminor Maje_ child, (NAMEOFPARENT) OF (NAME CHILD) (GENDER) in _. Sacramento California bom on 12/27/2017 ( STATE) (DATE) , (cry) relinquishand surrenderthechildforadoptionto_TheFamily Inc. Network, do hereby (NAMEOF AGENCY) CA 95678 ( 916 ) 480-1101 126 Grove Street,Roseville, NUMBER) (TELEPHONE {AGENCYADDRESS) by theCaliforniaDepartment of SocialServicesor authorizedby Welfare and Code Institutions an organizationlicensed 46130 tofindhomes for and children to placechildreninhomes foradoption. [] | amnot naming theprospectiveadoptive for parent(s) my child. {fr | amnaming the person(s) following as the adoptive prospective parent(s): BillyDeVore and lisa Grijalva {FULL NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S)) isnot placed inthe home ofthe named person(s)ormy childisremoved from thehome beforethe ifmy child the adoption iscompleted,the agency willnotifyme. | have wili 30 days fromthe date ofthe noticetorescind take relinquishment, no action orselectanother placement formy child.If |do notrescind therelinquishment withinthe30-day period,theagency may placethechildina home that theagency selects, thatwhen thisrelinquishmentisfiledwithand acknowledged by the Department California of Social |fullyunderstand Services, my all to rights thecustody, servicesand eamings child phthe and forthe any responsibility careand supportof thechild be will jerminated. AY; ‘ ‘—tf_ f “Tf 5 oe Z f~ cS £1 Zi ie rH" c tis/ (DATE} GHPASENT) (SIGNATURE The foregoingrelinquishmentwas signed on py Jessenia Rivera-Hinogjos inthe presenceof: (ATED {NAMEOFPARENT) if Patcicia, Stan e\& (Are: ¢ = —_ Joseph Montane ) (NAMEOFWITNESS) =. OZZZ MELE STATE OF CALIFORNIA A COUNTY OF 4 x fAMEYV df me On this day of A A as, ,20 18 me, , before | uke Wj eonard MSW A \ {NAMEOF AGENCY AUTHORIZED OFFICIAL) an authorized of officialthe The Family Network, inc an NAMEOFAGENC organizationlicensed by theCaliforniaDepartment ofSocial Servicesor @ thorized by Welfare and Code Institutions Section 16130 to find homes for children and to place children in homes for adoption, personally appeared_jessenia Rivera-Hingjas known to ms tobe the personwhose names scribedtothe PARENT) (NAME OF withininstrumentand acknowledged to me thathe/she e PRE OF a’ RRS AR Sociai Worker AD$01 {TITLE} (ENGYSP) {6/14) AD AND AD 503 - REPLACES 021 = ? EXHIBIT A DEPARTMENT CALIFORNIA OFSOCIALSERVICES OF STATE ANO - HEALTH CALIFORNIA HUMAN AGENCY SERVICINS STATEMENT OF UNDERSTANDING AGENCY ADOPTIONS PROGRAM the child to the adoption agency so the a child means permanently giving Relinquishing You permanently give the child tothe choose other parent(s) toadopt the child. agency can g and the relinquishment signing this Statement of Unde rstandin adoption agency by these documents any rights as a parent toyour child once document. You willno longer have CaliforniaDepartment ofSocial Services. been filedwith and acknowledged by the have of the child,you should be aware thai thought to be a biological/presumed father Ifyou are the child even ifyou deny legal rightsand responsibilitiestoward under the law you have tophysical custody to took forlegalcounsel toobtain the right paternity.You also have a right help you. child,there are services availableto child. you If want to be a parent tothe of the decision. You should know allthe childto the adoption agency is avery important Giving your e you make your ion. decis itsadvantages and disadvantages befor factsabout and it weigh To Complete The Statement Of Understanding: Instructions OF UNDERSTANDING AND THE RELINQUISHMENT BEFORE YOU SIGN THIS STATEMENT TO WITH YOUR SOCIAL WORKER. BE SURE DOCUMENT, READ BOTH VERY CAREFULLY ABOUT ANYTHING YOU DO NOT UNDERSTAND. ASK QUESTIONS carefullythought about giving your childto the Statement of Understanding only afteryou have 1. Complete this by prospective adoptive (s) parent are sure you want your child adopted and raised adoption agency and you selected by the on adopti agency. If youdo not understand a statement, ask your social each ofthe statements inthisdocument very carefully. 2. Read worker to explain you it to untilyou do understand. your in initials the box next tothe number ofthatstatement. if youunderstand and agree with a statement, put 3. your social worker's explanation, do not the initial agree, or if youdo not understand a staternentafter 4. If youdo not box. Ask formore help and time in making your decision. Two witnesses must be present when you sign your all initialed the boxes, sign your name at theend. 5. If youhave ifthisform is signed outside of theirnames afteryours. (Witnesses are not necessary name and they willsign California). and the relinquishment document once ithas been 6. You willreceive a copy of thisStatement of Understanding compieted. must be used with one of the following forms: This form 501, AD 501A, AD 504, AD 583, AD 584, or AD 4339. AD P. . Father Bislogica’Presumed who a Child of Detained, Is Not Court a Juvenile age 1 of 6 AD 885 ora Mother (3/14) Ward the ofa Legal (This Guardian. AD replaces form 4338) Care, in Out-ol-home Depentient or EXHIBIT A OF DEPARTMENT CALIFORNIA SERVICES SOCIAL OF STATE AND ~ HEALTH CALIFORNIA HUMAN AGENCY SERVICES STATEMENT OF UNDERSTANDING of a Child Who Is Not Detained, a Juvenile Court Mother or a Biological/Presumed Father Care, or the Ward of a Legal Guar dian Dependent in Out-of-home Date ofBirth 12/27/2017 Name ofChild Miles Rivera tohelp me in the relinquishment process and the adoption 1 iunderstand |have the rightto look fora lawyer & can refer me to publiclegal help inmy community. agency Ba isto me tell about itsadoption planformy child. |understand the agency foradoption toother professional people, my family |may talkabout my plan to give up my child |understand and friends. and the relinquishment document, |shall no longer be 4. |understand if|sign thisStatement ofUnderstanding Department of with and acknow ledged by the ia Californ e my child'slegalparent once these documents arefiled Social Services. This means: be responsible forthe care ofmy child;and A. {shall no longer to the custody,services or earnings of my child. B. {shallno longer have any right there are other places the agency can referme to that |understand if|am not sure | want to giveup my child, 2S withfamily,health, money and other problems. could help me giving my childtothe adoption agency. 6. [understand that bysigning the relinquishment | am PS adoptive parent(s), |am givingup the rightto If|sign a relinquishment thatdoes not name the prospective A. about who adopts my child be will made by prospective adoptive s) parent( and the finaldecision select the the adoption agency. the prospective adoptive parent(s)for my child. C iam not naming adoptive parent(s), |am giving my child to the B. If| sign a relinquishment that names the prospective with the person(s) named on the relinquishment adoption agency which intends to place my child document. followingperson(s) as the prospective adoptive parent(s): Sree 1am naming the BillyDeVore and Lisa Grijaiva person(s) or my childis removed from the home before Ifmy childisnot placed inthe home of thenamed the adoption iscompleted: return receipt requested, within 72 hours of the The agency: willsend me a notice by certifiedmail, (1) my childfram the home. |must not toplace my childforadoption orthe decision to remove decision such a notice. keep the agency informed ofmy address if want | toreoeive days from thedate the notice was mailed tome to either: (2) |shalihave 30 rescind the relinquishment if| deliver,or have a. Rescind the relinguishment. The agency will a writtenrequest to rescind the relinquishment tothe agency delivered by mail or othermeans, beforethe end ofthe 30-day period,or the 30-day period, |shall lose my rightto rescind the b. Take no action.If| take no-action during agency willselectadoptive parent(s) for my child,or relinquishment and the child. during ff, the 30-day period, |select another person(s) c. Select another placement formy | shallrescindthe relinqu initial ishment and complete a new withwhom my childis tobe placed, the person(s) withwhom | then wish theagency fo place my relinquishment document ing identify child. Who of a Child Is Not Detained, Court a Juvenile AD885 Mother (3/14) ora Father Biological/Presumed Page 2 of6 Ward or the of a Legal (This Guardian. AD replaces form 4338) Care, in Out-ol-nome Dependent EXHIBIT A parent(s) and the birth relatives,including the birthparents, may fu 7. |understand that the prospective adoptive continuing corttactbetween the birthrelatives,including enter into an enforceable writtenagreement to permit the birthparents, and the child the if court approves. agency, |may place my child foradoption with if| decide not to give my childto the adoption ae 8. |understand s). parent( This iscalled an only to an adoption of my child by ese this/th parent(s) | find myself and agree Independent Adoption. granted incourt, allinheritance rights from any blood relatives §S 9. |understand aftermy child'sadoption has been willor in a trustwhich specificallyincludesmy child. My willend unless they have made arrangemenis intheir inheritfrem his/her prospective adoptive parent(s). chiidwiltlegally and the relinquishment document, | can take them back aX 10. |understand If|sign thisStatement of Understanding or before ithas been filedwith and acknowledged by during any holding period referredto inNumber 18 below |also signed a “Waive r of Right To Revoke Department of Social Services, unless the California the relinquishment is If|signed a Waiver of Right To Revoke Relinquishment, Relinquishment” (AD 929A). Section where next s busines day as noted on the Waiver inthe irrevocable immediately or atthe close ofthe unless the waiver isvoid or the relinquishment is “Birth parent must one initial of the following statements:” rescinded. must return my child tome within three working days A. Under normal circumstances the adoption agency should ittake more than seven calendar days. and in no case parent continue will unless taken away by other legalaction. B. The rightsand responsibilitiesas my child's to me would hurt or otherwise harm my child, the C. the adoption agency believes returning my child child ive protect services agency. The adoption agency willmake an immediate referralto the county’s agency willletme know inwritingifthey do this. Social Services has filedand acknowledged my signed | understand once the California Department of ik 11. relinquishment itisfinal,and returned to me unless the adoption agency agrees or A. |cannot stop the relinquishment and have my child on the relinquishment and my chiidisnot placed the prospective adoptive parent(s) is/arenamed unless is completed. or my child isremove d from thehome before the adoption inthe named home agency willinform me inwriting ofthe reason(s) for B. Ifthe adoption agency does not agree, the adoption not returning my child. the rightsand responsibilitiesas my child'sparent will C. tfthe adoption agency agrees to returnmy child, continue unless taken away by other legalaction. itwillnormally take three working days and inno case D. ifthe adoption agency agrees toreturn my child, can ittake more than seven calendar days. or the subject of a petition forjuvenile court | understand that if the child isa juvenile court dependent our 12. e juvenil court,the child'slawyer, and agency must provide written tion notifica to the the jurisdiction, adoption ifany, ofthe relinquishment withinfivecourt days. my lawyer, agency must answer my questions about his/her before my child’islegally adopted, the adoption mr 43. understand {| tion informa about the any future time,the agency must give me ailknown situation. If|ask for information at my child has been placed foradoption, the approximate date status of my child’sadoption, including whether was not completed or was vacated forany reason, whether the adoption was completed and, ifthe adoption adoptive placement ofmy childisagain being considered. of my address if|want to know when my child {understand | must keep the adoption agency informed A. in an adoptive home and when my child was legally adopted. was placed Pp 30f6 Who of 3 Chiid is Not Court a Juvenile Detained, 885 Mother {3/14} or Father 2 Biologicali/Presumed age 30 AD form (This AD replaces 4338) of Care, in Out-ol-home theWardofa Guardian. Legal Dependent EXHIBIT A parent(s) and the birth relatives,Including the birthparents, may iu 7. \ understand that the prospective adoptive continuing contact between the birth , relatives g includin enter intoan enforceable writtenagreement to permit the birthparents, and the child the if court approves. agency, |may place my child foradoption with if| decide not te give my child tothe adoption a 8. |understand parent(s). This is called an and agree only to an adoption of my childby this/these parent(s) | findmyself Independent Adoption. granted incourt, allinheritance rightsfrom any biood relatives g8 9. |understand aftermy child'sadoption has been willor in atrust which specificallyincludes my child. My