Fillable Form Dss-1802 - Consent To Adoption By Parent (Page 2 of 3) in pdf

12.

That the name and address of the court, if known, 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.



That I understand that this is my second Consent to Adoption by the same adoptive parents and is

thereby irrevocable.

15.

That I understand that if I am a placing parent and a preplacement assessment of the prospective adoptive

parents is required and placement of the minor child with that parent occurs before the preplacement assessment is

given to me, then my time to revoke this Consent shall be either five business days after the date I receive the

preplacement assessment or the remainder of the 7 day period described above, whichever is longer. (The date of

receipt is the earlier of the date of actual receipt or the date established by G.S. 48-3-307 in the event the prospective

adoptive parents cannot, after the exercise of due diligence, locate me for delivery of the preplacement assessment.)

16.

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.

17.

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]

[Guardian Ad Litem of the Mother/Father] [Guardian]

____________________________________________________

Address

DSS-1802 (Rev. 11/2014)

Child Welfare Services

Page 2 of 3

Form Dss-1802 - Consent To Adoption By Parent Page 2