Form Dss-5189 -Consent To Adoption By Parent Who Is Spouse Of Stepparent

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STATE OF NORTH CAROLINA
COUNTY
CONSENT TO ADOPTION
BY PARENT WHO IS SPOUSE OF STEPPARENT
(STEPPARENT ADOPTION)
I, ______________________________________________________________________________________, declare:
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 have legal and physical custody of the adoptee, and the child has resided primarily with me and his/her
stepparent since _________________________, ___________;
5.
That I hereby voluntarily consent to the adoption of said child by his/her stepparent, ____________________
________________________________________________________, who is my spouse;
(Full name of petitioning stepparent)
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 the
adoptee's birth or prior adoptive [mother] [father] will be terminated, including all rights of the adoptee to inherit as a
child from and through _______________________________________________________________, and that the
adoption
(Full name of birth or prior adoptive mother/father)
will extinguish any existing court order of custody, visitation, or communication with the adoptee, except that
__________________________________________________________________ will remain liable for past due child
(Full name of birth or prior adoptive mother/father)
support payments unless legally released from this obligation;
8.
That I understand that the adoption will not terminate the legal relation of parent and child between myself
and the adoptee;
9.
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;
DSS-5189 (Rev. 11/2014)
Child Welfare Services
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