1. Form 574I Grandparent Acknowledgement – Instructions Page 1 of 1
FORM 574
ACKNOWLEDGMENT BY GRANDPARENT(S) AND/OR GUARDIAN(S)
INSTRUCTIONS
Form 574 is signed by the parent(s) or guardian of a minor who is voluntarily
surrendering his/her child for adoption to DHR. Although the Form 574 is not legally
required for a child to be surrendered by a minor parent, it may be useful in allowing
the grandparent(s) or guardian(s) to express their support of the decision.
Each of three (3) copies of Form 574 must contain original signatures and raised
notary seal. One copy must be attached to the original of the child's Life History, the
second copy is for the county file and the third copy is for the signer(s).
Form 574 must be typed and any corrections must be initialed by all parties.
The child's name and birth date must be exactly the same as they appear on the
birth certificate. The unofficial witness must not be the person who signs the
Affidavit of Department Representative. The notary may not be the caseworker
who has worked with the family.