Petition For Adoption Of A Minor Child Page 2

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The names of any individuals whose consent, relinquishment, or termination of rights may be necessary
but have not been obtained are listed in an attached document.
4.
That the adoptee was born on in the State/Country of ___________________ on or about the __________ day
of _________________________ in the year ____________.
5.
That as far as petitioner(s) are able to ascertain, said minor child is the owner of or is entitled to personal property
of the value of $______________ and real property of the value of $_______________, described as follows:
__________________________________________________________________________________________.
6.
That said adoptee was placed for the purpose of adoption with the petitioner(s) by:
Agency
Parent/s
Guardian of the Minor
on the __________________ (date)
If placed by agency, give name and address of agency consenting to the placement________________________
__________________________________________________________________________________________
If waiver of placement under N.C.G.S. 48-2-301(a) is needed, address in #13 below.
7.
If the adoptee is not in the physical custody of the petitioner(s), state the reason why the petitioner(s) do/does not
have physical custody and the date and manner in which the petitioner(s) intend/intends to acquire custody:
__________________________________________________________________________________________
8.
That the provisions of the Interstate Compact on the Placement of Children (ICPC), N.C.G.S. 7B - 3800 et. seq.,
were followed, or a statement is attached describing the circumstances of non-compliance or that the ICPC does
not apply.
9.
That the affidavit required by the Uniform Child Custody Jurisdiction and Enforcement Act, Chapter 50A of the
General Statutes, if applicable, is attached to the petition.
10.
That petitioner(s) seeking adoption herein is/are
single; or
married. If married, give date of that
marriage ________________________________. The petitioner(s) is/are a fit person(s) to have the custody,
supervision, and training of said child, and have the resources, including those available under a subsidy for an
adoptee with special needs, to provide for the care and support of the adoptee.
11.
That petitioner(s) desire(s) and agree(s) to adopt and treat the adoptee as their/his/her lawful child and
desire(s) that the relationship of parent(s) and child be established between them/him/her and said child; and
upon adoption, the said adoptee shall inherit real and personal property by, through, and from the said
petitioner(s) in accordance with the statutes of descent and distribution.
12.
That the petitioner(s) is/are
related or
not related to the said child specified in G.S. 48-3-301(b) as follows:
__________________________________________________________________________________________
13.
Enter any special allegation not yet given, such as child 12 years of age or older, whether spouse is deceased or
adjudged incompetent, whether waiver of placement needed, etc.
__________________________________________________________________________________________
__________________________________________________________________________________________
WHEREFORE, YOUR petitioner(s) pray(s) that the relationship of parent(s) and child be established between petitioner(s)
and said adoptee; and that the name of said adoptee be changed to:
____________________________________________________________ as hereinabove written and authorized by law.
DSS-1800 (Rev. 11/2014)
Child Welfare Services
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