Dss-5191 Disclosure Of Fees & Expenses - Nc Department Of Health And Human Services

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STATE OF NORTH CAROLINA
IN THE GENERAL COURT OF JUSTICE
DISTRICT COURT DIVISION
___________________ COUNTY
BEFORE THE CLERK
______ SP ____________
AFFIDAVIT
_______________________________________
(Full name of petitioning parent 1)
DISCLOSURE OF FEES & EXPENSES
________________________________________
(Full name of petitioning parent 2)
FOR THE ADOPTION OF
_____________________________________________________
(Full name by which adoptee is to be known if adoption granted)
In accordance with G.S. 48-2-602, this Affidavit is being made to account for any payments or
disbursements made or agreed to be made by petitioner(s) in connection with this adoption and is being
filed with the court at least 10 days before entry of the Final Decree. This affidavit includes the amount
each payment or disbursement and name and address of each recipient as allowed by G.S. 48-10-103.
Description of Expenses/Fees
Name & Address of Recipient
Amount
_______________________________________________
Adoptive Parent 1
_______________________________________________
Adoptive Parent 2
DSS-5191 (Rev. 11/2014)
Child Welfare Services
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