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

  1. Name of Child:

  2. Sex :

  3. Date of Birth:

  4. Abandoned/Relinquished:

  5. Date of Admission into the Agency :

  6. Date on which declared legally free for adoption:

  7. Date on which ACA assistance sought :

  8. *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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