Dss-5191 Disclosure Of Fees & Expenses - Nc Department Of Health And Human Services Page 2
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1
2STATE OF NORTH CAROLINA
___________________ COUNTY
Sworn to and subscribed before me this the _________ day of _________________________, ________
(SEAL)
________________________________________
Notary Public
My commission expires: _______________________________________
Note:
One DSS-5191 is filled in by the adoptive parent(s) for presentation to the Clerk of Superior Court who
then forwards it to the Division of Social Services, State Department of Health and Human Services.
DSS-5191 (Rev. 11/2014)
Child Welfare Services
Page 2 of 2
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