WPCM  
      `     =hE>5gB\6\kWShaG{`9NOS!>rkmmef__BNIW^e8<~(pVGQ$AAyD*m_vSysfa[}4̙zǀZ%\AS"i~P\qjo^OʑoR}MZm(a쿤O~2,p֝Cx/{椄v'+WBt;s}C9QyCaRjc{C蓩j29veϠ@A¦3m&}'dZa-D\+}X2	Bǒq[u@ۄ?>6jw9"I7ex	kؼ\D+|q%a~»Hn/ƞ$^&UD{mj5{/.N+.r[筀"i,ǁn9o}΅¸7E	}9W {           #        U   N     	%        0   :     0        0        0        0        0        0        0        0      ~  0      ]  0      9  0        0        0        0        0        0      X  0      (  0        0        0        0      ~  0      Y  0      1  0         0         0      !  0      s"  0   0   <#  0   <   l#  0      #  0   >   f$  0   v   $  0   `   %  0   `   z%  0   `   %  0   `   :&  0   `   &  0   8   &  0      2'  0   2   (  0      6(  0   :   2)  0   Y   l)  0   _   )  0   
  $*  0   j  .+  0     ,  	B   *   .  	D   /   F.  	D   +   u.  0     .  	D   /   $0  0      S0  0   6   !1  0     W1  0   :   _2  0   ^   2  0   <   2   U   6   33   U$   >   i3   U   *   3  	1      3   U   @   X4   U   ,   4   	      4  0   U   4   	      )5  N      95  ^      ;5  w      G5  4      K5        _5        n5  	m      p5   U   >   5  0   U   5  0      6  0      7  0      7  0      8  0      9  0      :  0      c;  0      :<  0   C   =  0      Q=  0      (>  0      >  0      ?  0      @  0      fA  0      .B  0      B  0   @   C  0      C  0      D  0      E  0      fF  0      1G  0      G  0      H  0      I  	1   e   =J   	      J  	1   u   J  	7   2   'K  0   c   YK   	      K   	      K   	      K   	      K   	      K   	      L  0   <    L     |   \L  0      L            L   b      hM   \ \ K J C D C 0 1 \ S A V I N   9 0 6 0                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      0                                                                                                                                                                 ( 9  	   Z  6 T i m e s   N e w   R o m a n   R e g u l a r           X    (                  $          USUS. ,      2   J   +       M   0 _ l e v e l 1            X 2  (   `	   h   p    x  2 2      3
   
       . .          5  +    `	   h   p    x  5         2   G   +       M   0 _ l e v e l 2             /  % `	 `	   h   p    x  / 2     3
   
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   h   p    x  , 2     3
   
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   
       . .          5  +    `	   h   p    x  5         2   >   +       M   0 _ l e v e l 5             &   h h   p    x  & 2     3
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   h   p    x  , 2     3
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 Ԁ      5  +    `	   h   p    x  5         2   ;          M   0 _ l e v s l 6             #      p    x  # 2     3
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   h   p    x  , 2     3
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       5  +    `	   h   p    x  5         2   2          M   0 _ l e v n l 9                    x   2     3
   
       5  +    `	   h   p    x  5         0                   . N o r m a l         <                   : D e f i n i t i o n   T         <   A           A   : D e f i n i t i o n   L        , 5  +    `	   h   p    x  5       5  +    `	   h   p    x  5     8                  6 D e f i n i t i o n         (   '           '   & H 1                             X      XX     (                 & H 2                    X      XX     (                 & H 3                    X      XX     (                 & H 4         X      XX     X      XX     (                 & H 5                    X      XX     (                 & H 6                    X      XX     2                 0 A d d r e s s         8   M           M   6 B l o c k q u o t e        ,    , 5  +    `	   h   p    x  5             5  +    `	   h   p    x  5     ,                  * C I T E         ,       d       l    * C O D E                K ?          < 6X  9   ` (  C o u r i e r   N e w         K     X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S     4                  2 E m p h a s i s         6                  4 H y p e r l i n k                    <                  : F o l l o w e d H y p e                   4       g       o    2 K e y b o a r d                K ?          < 6X  9   ` (  C o u r i e r   N e w         K     X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S     <                 : P r e f o r m a t t e d     /  %    
  , K k     %#/            K ?          < 6X  9   ` (  C o u r i e r   N e w         K     X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S /  %    
  , K k     %#/     <                 : z  B o t t o m   o f       7 5   (                   X                 7                ? A          % 2  A   `   A r i a l         ? 7 6   (                   X                 7          X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S   &              d          d   4 )     1                        d x    d  '                              d x    d    <                 : z  T o p   o f   F o r     7 8   (                   X                 7                ? A          % 2  A   `   A r i a l         ? 7 6   (                   X                 7          X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S  4 )     2                        d x    d    0       K       S    . S a m p l e     K ?          < 6X  9   ` (  C o u r i e r   N e w         K S @           \	  	   `  & T i m e s   N e w   R o m a n         S     0                  . S t r o n g         8       d       l    6 T y p e w r i t e r                K ?          < 6X  9   ` (  C o u r i e r   N e w         K     X      XX S @           \	  	   `  & T i m e s   N e w   R o m a n         S     4                  2 V a r i a b l e         :                  8 H T M L   M a r k u p     B
   
                2       
            0 C o m m e n t     B
   
 < 6X  9   ` (  C o u r i e r   N e w          \	  	   `  & T i m e s   N e w   R o m a n         % 2  A   `   A r i a l                          (5h        C E K Q W ] c i o A u t o L i s t 1     1 .   1 .   1 .   1 .   1 .   1 .   1 .   1 .                     ( 9  	   Z  ( T i m e s   N e w   R o m a n           , c  A   Z   A r i a l            S D U _ 5       (   -               2$       
   !    USUS. ,       S D U _ 7     /=Z         K=    :i +003| x                    U   \	  	   `   & T i m e s   N e w   R o m a n             *       +           ( _ 2 6     2      3
   
       . .        *   G   +       M   ( _ 2 5             /  % `	 `	   h   p    x  / 2     3
   
       . .          5  +    `	   h   p    x  5         *   D   +       M   ( _ 2 4             ,  " 
   h   p    x  , 2     3
   
       . .          5  +    `	   h   p    x  5         *   A   +       M   ( _ 2 3            `	 )   	  h   p    x  ) 2     3
   
       . .          5  +    `	   h   p    x  5         *   >   +       M   ( _ 2 2             &   h h   p    x  & 2     3
   
       . .          5  +    `	   h   p    x  5         *   ;   +       M   ( _ 2 1             #      p    x  # 2     3
   
       . .          5  +    `	   h   p    x  5         *   8   +       M   ( _ 2 0            h       p    x    2     3
   
       . .          5  +    `	   h   p    x  5         *   5   +       M   ( _ 1 9                p p    x   2     3
   
       . .          5  +    `	   h   p    x  5         *   2   +       M   ( _ 1 8                    x   2     3
   
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   
 Ԁ    *   G          M   ( _ 1 6             /  % `	 `	   h   p    x  / 2     3
   
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   h   p    x  , 2     3
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   
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   
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   
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   
 Ԁ      5  +    `	   h   p    x  5         (   2          M   & _ 9                    x   2     3
   
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   
     (   G          M   & _ 7             /  % `	 `	   h   p    x  / 2     3
   
       5  +    `	   h   p    x  5         (   D          M   & _ 6             ,  " 
   h   p    x  , 2     3
   
       5  +    `	   h   p    x  5         (   A          M   & _ 5            `	 )   	  h   p    x  ) 2     3
   
       5  +    `	   h   p    x  5         (   >          M   & _ 4             &   h h   p    x  & 2     3
   
       5  +    `	   h   p    x  5         (   ;          M   & _ 3             #      p    x  # 2     3
   
       5  +    `	   h   p    x  5         (   8          M   & _ 2            h       p    x    2     3
   
       5  +    `	   h   p    x  5         (   5          M   & _ 1                p p    x   2     3
   
       5  +    `	   h   p    x  5         &   2          M   $ _                    x   2     3
   
       5  +    `	   h   p    x  5      Y Z [ \ ] ^ _ `          3 5 ; A G M S Y _ 1     1 .   1 .   1 .   1 .   1 .   1 .   1 .   1 .    T e x t 2                    3#   3 7 = C I Q Y a g       1 .   a .   i .   ( 1 )   ( a )   ( i )   1 )   a )            m    i )                                           (       ;           3$       2  #      0
   
 .3
   
 0      T e x t 3    T e x t 4    T e x t 5    T e x t 6    C h e c k 1    C h e c k 2       <                    : D e f a u l t   P a r a      
   r   
 F  '    USUS. ,      _           "   X     A " 10/01/10    H   $           $   4 B o d y   T e x t   B o d y   T e x t       X      XX                     P a g e      o f     &  
   !    USUS. ,      _         D  XV X  X X         z      8    % %       d                  d  8 @    VV)   C  X  X XD XV 183# D  XV X  XC X   # Ԉ   	 d      3   	    p    x   (#   X3    33     =      X   X       d                 d=   w         O  X  X XD XV @    ::  INTHEDISTRICTCOURTOF_____________COUNTY,KANSAS   	 P    INTHEINTERESTOF:   	 
=   Ѐ   	 X      _  .  0      p" (#    pX0 Name% l    -     __________________________________-     % l          p CaseNo.% p    -     ______________________-     % p   5      	 s      .  _   <   	    z    x   (#   p" (#<       33  DOB% q    -     xx# D  XV X  XO X  # % q       O  X  X XD XV /xx# D  XV X  XO XZ  #  O  X  X XD XV /____% r    % r      % s    -     % s      ԀA0% t    % t   !   Ԁmale% u    # D  XV X  XO X  #  O  X  X XD XV Ԁ0% u   D   Ԁfemale   	       _  .   <        z p" (#    z X<    33     # D  XV X  XO Xt  #  C  X  X XD XV @    M
M
  RELINQUISHMENTOFMINORCHILDTOAGENCY   	 		   @      PursuanttoK.S.A.382268   	 

   NOTICETOPARENT:Thisisanimportantlegaldocumentandbysigningityouare   	 J   permanentlygivingupallcustodyandotherparentalrightstothechildnamedherein.You   	 i   aretoreceiveacopyofthisdocument.   	          I,򀀀 C  & %  XC X (Name)# C  X  X %C &E  # 󀀀, O  X  X  XC X 0# C  X  X  XO X  # Ԁmother O  X  X  XC X 0# C  X  X  XO X  # Ԁfatherof򀀀(Childsname)󀀀,   	 V   aminorchild,state:   	 u   1.     Thechildwasbornon C  & %  XC X Ԁ(Dateofbirth)# C  X  X %C &	  # at򀀀 C  & %  XC X (Placeofbirth)# C  X  X %C &e
  # Ԁat򀀀: O  X  X  XC X 0# C  X  X  XO X
  # Ԁa..m. O  X  X  XC X 0# C  X  X  XO XD  # Ԁp.m.   	    2.     Iresideat򀀀,Countyof򀀀andStateof򀀀.   	 I   3.     Iamoftheageof򀀀yearsandwasbornon򀀀.   	    !     	                  !  
B                   ( 5h        8                               3                            m                    " o  3                  "      o  3   2  5h      4
   
 .3
   
 0          ThechildisneitheramemberofnoreligibleformembershipinanIndiantriberecognized   	 !Q   byfederallawnoranAlaskanNativerecognizedbyfederallaw. o  3     ݌    "l (#(#  Ќ	     " o  3                  "      o  3   2  5h      5
   
 .3
   
 0          IdoherebyrelinquishthechildtotheSecretaryofSRS,whichIunderstandtheSecretary   	 %   willhavefullpowerandalltherightsofabirthparentorlegalguardianoverthechild,   	 !&   includingthepowertoplacethechildforadoptionandgiveconsentthereto. o  3  )   ݌    <'  (#(#  Ќ	     " o  3                  "      o  3   2  5h      6
   
 .3
   
 0          Iwishto,andIunderstandthatbysigningthisrelinquishmentIdo,permanentlygiveupall   	 r)#    custodyandotherparentalrightsIhavetosuchchild,includingtherighttoreceivenotice   	 *)$!   ofanysubsequentadoptionproceedingsinvolvingthechild. o  3  !   ݌    +D%" (#(#  Ќ	     " o  3                  "      o  3   2  5h      7
   
 .3
   
 0          IhavereadandunderstandtheaboveandIamsigningitasmyfreeandvoluntaryact. o  3  
   ݌     (#(#  Ќ	     Dated򀀀,at򀀀: O  X  X  XC X 0# C  X  X  XO XG  # Ԁa.m. O  X  X  XC X 0# C  X  X  XO X  # Ԁp.m.0    p     	Q p(#p(#                     z     p _______________________________   	 
p                      z     p SignatureofParent   	                       z     p       @  X  X  XC X  x    @  X  X  X@ X  @  X  X  X@ X           x  n            CERTIFICATEOFATTORNEY x  n     ݌   	 v
   Ќ     @  X  X  X@ X  @  X  X  X@ X 	      x    @  X  X  X@ X  @  X  X  X@ X           x               # C  X  X  X@ XN  #      Iamalicensedattorneyrepresenting @  X  X  XC X Ԁtheparentnamedaboveandhaveexplainedtothat   	 H   parentthatbysigningthisconsenttheagencywillexerciseallparentalrightstothechildandthat   	 c   parentconfirmedthatintentionanddesire. x  ٦     ݌   	 ~   Ќ     @  X  X  X@ X  @  X  X  X@ X 	      x    @  X  X  X@ X  @  X  X  X@ X           x           x       ݌̌     @  X  X  X@ X  @  X  X  X@ X 	      x    @  X  X  X@ X  @  X  X  X@ X           x          # C  X  X  X@ X  # Date:򀀀 @  X  X  XC X 0    z 0    pz(#z(# ______________________________ x    q   ݌     p(#p(#  Ќ     @  X  X  X@ X 	      x    @  X  X  X@ X           x  ٫                           z     p SignatureofAttorney x  ٫     ݌   	 3   Ќ     @  X  X  X@ X 	      x    @  X  X  X@ X           x               0     0    (#(# 0    z(#(# 0    pz(#z(# _        S.Ct_        .#_______________ x    
   ݌    N p(#p(#  Ќ     @  X  X  X@ X  @  X  X  X@ X 	      x    @  X  X  X@ X  @  X  X  X@ X           x  >         x  >     ݌̌     @  X  X  X@ X  @  X  X  X@ X 	      x    @  X  X  X@ X  @  X  X  X@ X           x  1         # C  X  X  X@ X  #  x  1       ݌̌     C  X  X  XC X 	          @      CERTIFICATEOFATTORNEYFORRELINQUISHINGMINORPARENT   	 q        Iamalicensedattorneyrepresentingtheparentnamedabove,whoisaminor.Ihavefully   	 "   explainedthatbysigningthisrelinquishmentthatparentispermanentlygivingupallparentalrights   	 &#   tothechildandthatparenthasstatedthatintentionanddesire.Iwaspresentattheexecutionofthis   	 A$   relinquishment.   	 \%   ?        z p (#     z p" (#? Date:򀀀    z 0    p 0 @  pp(#p(# _____________________________    '.! p(#p(#                     z     p SignatureofAttorney   	 (I"                      z     p _        S.Ct_        .#_______________   	 )d#         @    *     	 +%"   Ї    e     @      ACKNOWLEDGMENTBEFOREJUDGEOFDISTRICTCOURT   	       @    *  ?        h p (#     z p? STATEOFKANSAS0    z 0    <z(#z(# 0    h<(#<(# )    O6 h(#h(#                     z     <     h )ss:   	 j	Q   COUNTYOF򀀀)   	 
l        I,򀀀,JudgeoftheDistrictCourt,򀀀,Judicial   	    District,herebycertifythat____________________________________,knowntometobethe   	    samepersonwhosenameissubscribedtotheforegoingrelinquishment,appearedbeforemethisday   	    inpersonand% E    % E   (   acknowledgedthat(she)(he)signedsuchrelinquishmentas(her)(his)freeand   	 		   voluntaryact,forthespecifiedpurpose.   	 '
              Ihavefullyexplainedthatbysigningsuchrelinquishment(she)(he)ispermanentlygiving   	 ]D   upallparentalrightstosuchchildand(she)(he)hasstatedthat(she)(he)understoodtheconsequence   	 x_   andthatpermanentrelinquishmentofparentalrightsis(her)(his)intentionanddesire.   	 z         Dated򀀀,at򀀀: O  X  X  XC X 0# C  X  X  XO Xe+  # Ԁa.m. O  X  X  XC X 0# C  X  X  XO X+  # Ԁp.m.    p    	                       z     <     h     p ______________________________   	                       z     <     h     p JudgeoftheDistrictCourt   	                       z     <     h     p     OR   	 9            _        ACKNOWLEDGEMENT_        ԀBEFORENOTARYPUBLIC   	 oV       STATEOFKANSAS0    z 0    <z(#z(# 0    h<(#<(# )      h(#h(#                     z     <     h )ss:   	 !   COUNTYOF򀀀)   	 "      ;.            Icertifythat򀀀,knowntometobethesamepersonwhose   	 %   nameissubscribedtotheforegoingrelinquishment,appearedbeforemethisdayinpersonand   	 ,&    acknowledgedthat(she)(he)signedsuchrelinquishmentas(her)(his)freeandvoluntaryact,forthe   	 G'.!   specifiedpurpose.   	 b(I"   Dated򀀀,at򀀀: O  X  X  XC X 0# C  X  X  XO Xm1  # Ԁa.m. O  X  X  XC X 0# C  X  X  XO X1  # Ԁp.m.    p    	 *$!                      z     <     h     p ______________________________   	 +%"                      z     <     h     p Notary   	 ,&#   MyCommissionExpires:___________________.   	 -'$   Ї                   z @      ACCEPTANCEOFCHILDBYAGENCY   	 4              I,򀀀,theundersigned,onbehalfoftheSecretaryofSRS,do   	 j	Q   herebyacceptcustodyof______________________,% G    % G   4   theaboverelinquishedminorchild.   	 
l   Date:򀀀    z 0    < 0    h<(#<(#     p      h(#h(#                     z     <     h     p ______________________________   	                       z     <     h     p Signature   	                       z     <     h     p ______________________________   	 		                      z     <     h 0    p Title    '
 p(#p(#  @    *     X  X  XC X     Authority   	         K.S.A.382268.   	         @ @  $  NotesonUse   	 5            Withtheconsentoftheguardianadlitemandthesecretary,aparentmayrelinquishparental   	 kR   rightspriortoahearingtoconsidertheterminationofparentalrights.Therelinquishmentshallbe   	 m   acknowledgedbeforeajudgeornotary.Iftherelinquishmentisacknowledgedbeforeajudgeor   	     notary,itshallbethedutyofthecourttoadvisetherelinquishingparentoftheconsequencesofthe   	 !   relinquishment.Ifaparentrelinquishesachildtothesecretarybasedonabeliefthattheotherparent   	 "   wouldrelinquishthechildorbefoundunfit,andneitheroccurs,therightsoftheparentwho   	 #   relinquishedbasedonthatbeliefshallnotbetherebyterminated.   	 %        IfthepersoncannotreadandunderstandEnglish,specificallystatehowtheywereinformed   	 (&    ofalltheirrightsandtheconsequencesofrelinquishment.# C  X  X  X X7  #     p    	 C'*!             @    *  
