Relinquishment Of Minor For Adoption By Parent Or Guardian Or Guardian Ad Litem Of The Mother/father Page 3

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STATE OF NORTH CAROLINA
____________________COUNTY
I, _______________________________________________________________________________, do hereby certify
(Name of official)
that ____________________________________________________________ personally appeared before me this day
Name of [Mother] [Father] [Guardian] [Guardian ad Litem of the Mother/Father]
and acknowledged the due execution of the foregoing document and that this document has been sworn to (or affirmed)
and subscribed before me. I further certify to the best of my knowledge and belief that the parent or guardian executing
the Relinquishment: read, or had read to him or her, and understood the Relinquishment; signed the Relinquishment
voluntarily; received an original or copy of his or her fully executed Relinquishment; and was advised that counseling
services are available through agency to whom Relinquishment is given.
I certify that I, the undersigned, am a Notary Public or one otherwise empowered to administer oaths or take
acknowledgments.
Witness my hand and seal this the _____________ day of _____________________________________, __________,
at _____________________________________________________________________________________________
(Place of Relinquishment)
Signature _____________________________________
(S E A L)
Title
_____________________________________
My commission expires _____________________________
NOTE:
Three DSS-1804 forms are signed. The original of this form is attached to the Consent to Adoption by Agency (DSS-
1801) and sent with the Petition for Adoption to the Division of Social Services, State Department of Health and Human
Services, by the Clerk of Superior Court. One copy of Form DSS-1804 is retained in the record of the county
department of social services or licensed private child-placing agency. One copy is given to the parent or guardian
or guardian ad litem of the Mother/Father relinquishing the child.
DSS-1804 (11/2014)
Child Welfare Services
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