Form Dss-5189 -Consent To Adoption By Parent Who Is Spouse Of Stepparent Page 2
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310.
That I hereby waive notice of any proceeding for adoption;
11.
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;
12.
That the name and address of the court in which the Petition for Adoption has been or will be filed are as
follows:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
13.
That I have been informed that the name and address of the person to whom any notice of revocation of this
consent can be sent are as follows:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
14.
That I understand that my Consent to the adoption of the minor may be revoked within 7 days following the
day on which it is executed, inclusive of weekends and holidays. If the final day of the period falls on a weekend or a
North Carolina or federal holiday, then the revocation period extends to the next business day.
15.
That I understand that to revoke my Consent to Adoption, as provided in G.S. 48-3-608, the revocation must be
made by giving written notice to the person specified in this Consent. Notice may be given by personal delivery,
overnight delivery service, or registered or certified mail, return receipt requested. If notice is given by mail, notice is
deemed complete when it is deposited in the United States mail, postage prepaid, addressed to the person specified in
this Consent at the address also specified. If notice is given by overnight delivery service, notice is deemed complete on
the date it is deposited with the service as shown by the receipt from the service, with delivery charges paid by the
sender, addressed to the person specified in this Consent at the address also specified. Forms to revoke my Consent may
be obtained from the Clerk of Superior Court in any county in North Carolina.
16.
That I understand that unless revoked in accordance with G.S. 48-3-608, my Consent to Adoption is final and
irrevocable and may not be withdrawn or set aside except under a circumstance set forth in G.S. 48-3-609.
____________________________________________________
Signature of [Mother] [Father]
____________________________________________________
Address
DSS-5189 (Rev.11/2014)
Child Welfare Services
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