Relinquishment Of Minor For Adoption By Parent Or Guardian Or Guardian Ad Litem Of The Mother/father
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4STATE OF NORTH CAROLINA
____________________COUNTY
RELINQUISHMENT OF MINOR FOR ADOPTION BY PARENT
OR GUARDIAN OR GUARDIAN AD LITEM OF THE MOTHER/FATHER
I, _______________________________________________________________________, being duly sworn, declare:
1.
That I was born on the ________ day of ____________________, ________, and have a permanent address at
_______________________________________________________________________________________________;
2.
That I am of sound mind and in full possession of my mental faculties;
3.
That I am the ____________________________________________________________________________
(Mother) (Father) (Guardian)(Guardian ad litem of the Mother/Father pursuant to G.S. 48-3-602)
of ____________________________________________________________, a _______________child,
(Original Name of Child – If known)
(Sex – If known)
born on the_________day of ___________________, ________, [or expected to be born
approximately________________________________ to ___________________________ ] in
_________________________________________________________________________________________.
(City or Town)
(County)
(State)
4.
That I hereby relinquish all rights to said child and surrender said child to ____________________________
[County Social Services] or [Director of ____________________________________, a licensed child-placing agency],
whose address is _________________________________________________________; such release being a voluntary
act on my part and without any demand on the part of the director of [social services] [licensed child-placing agency];
5.
That I voluntarily consent to the permanent transfer of legal and physical custody of said child to the agency for
the purposes of adoption:
A.
with a prospective adoptive parent selected by the agency; or
B.
with a prospective adoptive parent selected by the agency and agreed upon by me, designated as:
______________________________________________________________________
6.
That this Relinquishment shall be valid and binding and shall not be affected by any oral or separate written
agreement between the agency and me;
7.
That I understand that when the adoption is final, all of my rights and duties with respect to the minor will be
extinguished and all other aspects of my legal relationship with the minor child will be terminated;
8.
That I have not received or been promised any money or anything of value for the relinquishment of the minor
except for lawful payments that are itemized on a schedule attached to this Relinquishment;
9.
That I hereby waive notice of any proceeding for adoption;
10.
That I have provided the agency with necessary background information or have signed releases that will
permit the agency to compile the information required by G.S. 48-3-205;
DSS-1804 (11/2014)
Child Welfare Services
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