Consent Of Child For Adoption (Stepparent Adoption)
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1
2STATE OF NORTH CAROLINA
__________________ COUNTY
CONSENT OF CHILD FOR ADOPTION
(Stepparent Adoption)
I, _____________________________________________________________________, being duly sworn, declare:
1.
That I was born on the __________ day of ____________________, _________, that my present address is
_____________________________________________________________________________________;
2.
By executing this document, I am voluntarily consenting to my adoption by _________________________
_____________________________________________________________________________________;
(Full name of petitioning stepparent)
3.
That I understand that my Consent may be revoked at any time before the Decree of Adoption is entered by
filing written notice with the Court in which the adoption petition is pending, which is
_____________________________________________________________________________________
_____________________________________________________________________________________;
4.
That the Consent shall be valid and binding and is not affected by any oral or separate written agreement
between myself and the adoptive parent(s);
5.
That in relation to my adoption, I have not received or been promised any money or anything of value for
my Consent;
6.
That I understand that the adoption will not terminate the legal relationship of parent and child between
myself and my parent, ____________________________________, who is the stepparent’s spouse.
(Name)
I further understand that the adoption will terminate the legal relationship of parent and child between
myself and my parent, _____________________________________, who is not the stepparent’s spouse,
(Name)
including all my rights to inherit from or through that parent, and will extinguish any court order of
custody, visitation, or communication with me, except that such parent’s obligation for past due child
support payments will remain unless legally released from that obligation; and,
7.
That I have read or had read to me and understand this Consent; been advised that counseling services may
be available through the county department of social services or a licensed child-placing agency; and been
advised of my right to consult with any legal counsel already appointed for me.
_________________________________________________
Signature – Adoptee’s Original Name
_________________________________________________
Address
DSS-5169 (Rev. 11/2014)
Child Welfare Services
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