This document is an acknowledgement by the grandparents or guardians of a minor parent surrendering a child to the Georgia Department of Human Services for adoption. They acknowledge their approval of the surrender and support the minor parent's decision to relinquish all rights to the child so that the Department may arrange an adoption. The grandparents/guardians, unofficial witness, and notary public provide their signatures and dates to the legal document.

1. GEORGIA DEPARTMENT OF HUMAN SERVICES
ACKNOWLEGEMENT BY GRANDPARENT(S) AND/OR GUARDIAN(S)
NOTICE TO GRANDPARENT(S) AND/OR GUARDIAN(S): This is an important legal document and by
signing it you are indicating your approval of your daughter’s/son’s surrender of said child.
*******************************
WE/I THE UNDERSIGNED, the parent(s) and/or guardian(s) of , of
(Name)
a minor, born,
,
hereby acknowledge our daughter’s son’s surrender of their child,
(Name)
born
,
to the Georgia Department of Human Services for placement for adoption.
(Name)
FURTHERMORE, we/I have read the surrender documents signed by said minor and we/I support her/his
decision to relinquish all of her/his rights to said child to the Georgia Department of Human Services and that
said Department may require for said child a legal adoption by such person or persons as may be chosen by
said Department or its authorized agents.
WITNESS my/our hand and seal this day of
,
.
Parent or Guardian Date
Parent or Guardian Date
Unofficial Witness Date
Sworn to and Subscribed before me this
day of , .
Form 57- Acknowledgement by Grandparent(s) or Guardian(s) (Rev. 12-2011) Page 1 of 1

2. Notary Public
My Commission Expires:
Form 57- Acknowledgement by Grandparent(s) or Guardian(s) (Rev. 12-2011) Page 2 of 1