This is to certify that
the _____(1)__________ gives clearance to the child
_____(2)______, Male/Female, born on ___(3)_______,
proposed by ________(4)__________ on ___(5)_____ for
his/her placement in inter-country adoption.
This is to further certify
that efforts have been made by the concerned Placement
Agency and this office to place the child in adoption
with an Indian Family in India, the details of which can
be seen in the enclosed statement.
Date of clearance:
Grounds of clearance:
(Signature &
Seal of the Chairperson ofACA)
(Signature &
Seal of the Member Secretary of ACA)
Note: (1) Name
of the ACA; (2) Name of the Child; (3) Date of birth of
the child; (4) Name of the Recognized Placement Agency;
(5) Date on which the child is placed on ACA assistance.
Particulars of the efforts
made for in-country adoption of the child
Name of Child:
Sex :
Date of Birth:
Abandoned/Relinquished:
Date of
Admission into the Agency :
Date on which
declared legally free for adoption:
Date on which
ACA assistance sought :
*Indian
Parents contacted by the concerned Placement
Agency:
Name, Address
& Telephone No.
Registration
No.
Date of
contact
Reasons (if
any) for not accepting child
Remarks of the
ACA on the efforts of the Agency
*9. Efforts made by the
ACA from its own list of Prospective Adoptive Parents:
Name, Address
& Telephone No. of the Prospective Parent
contacted by the ACA
Registration
No. & Date
Date of
referral to the parent
Response from
the parent and the reasons (if any) for the
child not being accepted
Remarks of the
ACA
*10. Efforts through
Inter-ACA Co-ordination:
Name of the
ACA’s contacted
Date on which
the details of the child circulated
Deadline for
reply (if any)
Date & details
of response (if any)
(Signature &
Seal of the Chairperson of ACA)
(Signature &
Seal of the Member Secretary of ACA)
If the ACA is not able to
find a suitable Indian parent from its own list within
15 days from the date of registration of the child for
assistance, then the child’s details should be
circulated to other ACAs and only if no response is
received from other ACAs, the concerned ACA may give a
clearance after 30 days stating the grounds of clearance
for inter-country adoption.
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