JFS 01666 - Permanent Surrender Form

SACWIS Case Number

By default, this field displays the current case number of the person selected in the Case Participant field. This is a required field.

Case Participant

Select the individual who is surrendering the child. This is a required field.

Role

Select the option that best describes the case participant's relationship to the child being surrendered. This is a required field.

Reason for Inability to Provide Care

Describe the case participant's reasons for wanting to surrender  the child. This is a required field.

Date of Assessor Counseling

Enter the date on which assessor counseling was provided. This is a required field.

Assessor Counseling and Surrender Alternatives

Describe the counseling given to the case participant and the alternatives to surrender that were discussed. This is a required field.

Location of Permanent Surrender

Enter the location where this form will be signed.

Date Permanent Surrender Taken

Enter the date when the case participant will sign the form.

Time Permanent Surrender Taken

Enter the time when the case participant will sign the form.

Name of Court

Enter the name of the court with jurisdiction over the surrender.