Form Dss-5190 - Consent To Adoption By Parent Who Is Not The Stepparent'S Spouse
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3STATE OF NORTH CAROLINA
_
COUNTY
CONSENT TO ADOPTION
BY PARENT WHO IS NOT THE STEPPARENT'S SPOUSE
(STEPPARENT ADOPTION)
I, ______________________________________________________________________________________, de clare:
1.
That I was born on the _________ day of __________________, _________, and have a permanent address at
_______________________________________________________________________________________________;
2.
That I am of sound mind and in full possession of my mental faculties;
3.
That I am the [mother] [father] of _______________________________________________, a __________
(Original Name of Child)
(Sex)
child, born on the ________day of ____________________, _______, in ____________________________________
(City or Town)
(County)
_______________________;
(State/Country)
4.
That I hereby voluntarily consent to the adoption of said child by his/her stepparent, _____________________
_______________________________________________________;
(Full name of petitioning stepparent)
5.
That I voluntarily consent to the transfer of any right I have to legal or physical custody of the adoptee to the
petitioning stepparent and the child's other parent, ______________________________________________________;
(Spouse of petitioner)
6.
That this Consent shall be valid and binding and shall not be affected by any oral or separate written agreement
between me and the aforenamed adoptive parent;
7.
That I understand that when the adoption is final, the legal relation of parent and child between adoptee and me
will be terminated, including all rights of the adoptee to inherit as a child from and through me, and that the adoption
will extinguish any existing court order of custody, visitation, or communication with the adoptee, except that I will
remain liable for past due child support payments, unless legally released from this obligation;
8.
That I have not received or been promised any money or anything of value for this Consent except for lawful
payments that are itemized on a schedule attached to this Consent;
9.
That I hereby waive notice of any proceeding for adoption;
10.
That I have read or had read to me and understand this Consent, been advised that counseling services may be
available through county departments of social services or licensed child-placing agencies, and been advised of the right
to employ independent legal counsel;
DSS-5190 (Rev. 11/2014)
Child Welfare Services
Page 1 of 3
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