I, A S/o …………………….resident of……………………. hereby declare that I am the natural father of B, and with my free consent, have given B in adoption to C, son of D resident of……………….on …………………….I further declare that from the date of the adoption, I will have no concern with B and he has become the son of the said C.

I have also taken the consent of my wife Smt …………………….to give my son……………………. in adoption to C.

IN WITNESS WHEREOF, etc . ………………….