Form Dss-5189 -Consent To Adoption By Parent Who Is Spouse Of Stepparent Page 3
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3STATE OF NORTH CAROLINA
____________________COUNTY
I, _______________________________________________________________________________, do hereby certify
(Name of official)
that ____________________________________________________________ personally appeared before me this day
Name of [Mother] [Father]
and acknowledged the due execution of the foregoing document. I further certify to the best of my knowledge and belief
that the parent executing the Consent: read, or had read to him or her, and understood the Consent; signed the Consent
voluntarily; received an original or copy of the fully executed Consent; and was advised that counseling services may be
available through county departments of social services or licensed child-placing agencies.
I certify that I, the undersigned, am a Notary Public or one otherwise empowered to acknowledge signatures under
Chapter 47 of the General Statutes of North Carolina.
Witness my hand and seal this the ___________ day of ______________________________________, ___________,
at _____________________________________________________________________________________________
(Place of Consent)
Signature _____________________________________
(S E A L)
Title
_____________________________________
My commission expires _______________________________
Note:
The original Consent to Adoption by Parent Who is Spouse of Stepparent is to be sent by the Clerk of Superior Court to
the Division of Social Services, State Department of Health and Human Services, attached to the Petition for Adoption.
A signed copy of the Consent is to be given to the person who signed the Consent.
DSS-5189 (Rev. 11/2014)
Child Welfare Services
Page 3 of 3
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