一、  本人為 男性: OO(OOOOOO 出生)之生母和唯一的監護人，因為無法扶養願意無條件的放棄親子關係並同意 OOO 和OOO 收養為養子(女)， 本人絕對不撤回此項同意。

      I, the signer of this document do as the biological mother and only guardian of the male child, OOO, born OOOOOO, due to inability to care for the said child , do irrevocably and unconditionally release myself from any biological ties to the child. I am in agreement with OOOand OOOadopting the said child as their own.

 二、收養手續應照中華民國法律及養父母所屬國家的法律辦理完成。本人也同意該嬰孩從台灣移民到養父母所屬的國家，絕對不撤回此項承諾。

    I am in full agreement with the adoption process that is done according to the laws and courts of Taiwan as well as the laws and courts of the country of the adopting family. I am in full irrevocable agreement to the child immigrating and being adopted to the country of the adopting family.

三、本人為 OOO之生母和唯一的監護人完全了解孩子被領養到美國去對於我本人沒有任何利益關係。本人也了解也同意不會因此出養案件而要求美國移民當局讓本人移民至美國或利用移民的方式去找孩子。

   I, the biological mother and only guardian of  the child(ren), OOO, do fully understand that this adoption in no way benefits me now or in the future. I understand that the child(ren) immigrating to America will not benefit me and I will not use this as a means to immigrate to the USA or to go searching for my child.

生母:OOO身分證:OOOO               簽章:

(生母)法定代理人:OOO

身分證:OOOOOOO               簽章:

中華民國 OO年OO月OO日