Relinquishment Of Minor For Adoption By Parent Or Guardian Or Guardian Ad Litem Of The Mother/father Page 2
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411.
That I have read or had read to me and understood this Relinquishment, been advised that counseling services
are available through the agency to which the Relinquishment is given, and have been advised of the right to employ
independent legal counsel;
12.
That I understand that my Relinquishment to Adoption of the minor may be revoked within 7 days
following the day on which it is executed, inclusive of weekends and holidays. If the final day of the period falls on a
weekend or a North Carolina or federal holiday, then the revocation period extends to the next business day.
That I understand this is my:
second Relinquishment for placement with the same adoptive parent
selected by the agency and agreed upon by me and is thereby irrevocable; or
second Relinquishment for placement by the agency with any adoptive
parent selected by the agency and is thereby irrevocable.
13.
That I further understand that if my Relinquishment is for the placement of my child with a prospective
adoptive parent selected by the agency and agreed upon by me as designated in Paragraph 5 B. above, and the adoption
of my child by that prospective adoptive parent will not be completed, I agree that pursuant to N.C.G.S. 48-3-704:
That I will receive notice by the agency at my address listed above, if the agency cannot
locate me after the exercise of due diligence, that the adoption will not be completed
and my revocation period will be 10 days, inclusive of weekends and holidays,
from the date of receipt of notice by the agency that the adoption will not be completed.
If I do not revoke my relinquishment within this 10 day period in writing and delivered
in the manner provided by G.S. 48-3-706, my relinquishment will be deemed a
general relinquishment, and the agency may place the child with a prospective adoptive
parent selected by the agency.
OR
That I do not wish to receive notice by the agency that the adoption will not be completed
`
and in the event of such an uncompleted adoption, I hereby consent to the adoption of my
child with any prospective adoptive parent selected by the agency.
14.
That I understand that to revoke my Relinquishment for Adoption, as provided in G.S. 48-3-706, the revocation
must be made by giving written notice to the agency to which the Relinquishment was given. Notice may be given by
personal delivery, overnight delivery service, or registered or certified mail, return receipt requested. If notice is given
by mail, notice is deemed complete when it is deposited in the United States mail, postage prepaid, addressed to the
agency at the agency’s address as given in the Relinquishment. If notice is given by overnight delivery service, notice is
deemed complete on the date it is deposited with the service as shown by the receipt from the service, with delivery
charges paid by the sender, addressed to the agency at the agency’s address as given in the Relinquishment. Forms to
revoke my Relinquishment may be obtained from the Clerk of Superior Court in any county in North Carolina.
15
That I understand unless revoked in accordance with G.S. 48-3-706 or #13 above, my Relinquishment is final
and irrevocable except under the circumstances set forth in G.S. 48-3-707.
____________________________________________________
Signature of [Mother] [Father] [Guardian]
[Guardian ad Litem of the Mother/Father]
____________________________________________________
Address
DSS-1804 (11/2014)
Child Welfare Services
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