STATE OF NORTH CAROLINA
COUNTY
CONSENT TO ADOPTION
BY PARENT, GUARDIAN, OR GUARDIAN AD LITEM OF THE MOTHER/FATHER
I, ______________________________________________________________________, being duly sworn, 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] [guardian] or [guardian ad litem of the Mother/Father pursuant to
G.S. 48-3-602] of ___________________________________________ (original name of child – if known), a
____________child (sex – if known), born on the ________day of ___________________, _______, [or expected to
be
born to ____________________________ on approximately ___________________ ]
in ______________________________________________________________________________.
(City or Town)
(County)
(State)
4.
That I hereby consent to the adoption of said child by _____________________________________________
(Full name of petitioning parent 1)
and ___________________________________________________;
(Full name of petitioning parent 2)
5.
That I voluntarily consent to the transfer of legal and physical custody to, and the adoption of the minor by, the
aforenamed adoptive parents;
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 parents;
7.
That I understand that when the adoption is final, all of my rights and duties with respect to the minor will be
extinguished and all aspects of the legal relationship between the minor child and the parent will be terminated;
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 provided the prospective adoptive parents or the prospective adoptive parents' attorney with the
written document required by G.S. 48-3-205 (Disclosure of Background Information);
11.
That I have read or had read to me and understood 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-1802 (Rev. 11/2014)
Child Welfare Services
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