Form Dss-1800- Petition For Adoption Of A Minor Child - Child Welfare Services Page 3
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3Attachments to petition (N.C.G.S. 48-2-305): _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
This the ______________ day of _________________________________________, ____________
____________________________________________ Signature of Petitioner 1
____________________________________________ Signature of Petitioner 2
________________________________________________ and ___________________________________________
(Full name of petitioning parent 1)
(Full name of petitioning parent 2)
being duly sworn, depose and say that he/she/they has (have) read the foregoing Petition and that the facts set forth
therein are true to his/her/their own knowledge, except as to matters therein set forth upon information and belief, and
as to such matters he/she/they believe(s) them to be true.
This ______________day of __________________________________, in the year ____________.
____________________________________________ Signature of Petitioner 1
____________________________________________ Signature of Petitioner 2
Subscribed to and sworn to before me this ___________ day of ____________________________________, _________
(S E A L)
____________________________________________________
Signature of Clerk of Superior Court or Notary Public
____________________________________________________
Printed Name of Clerk of Superior Court or Notary Public
My commission expires ________________________________
_______________________________ _________________________________________________________________
Attorney for petitioner/s
(Mailing Address)
_______________________________ _________________________________________________________________
(Telephone Number)
(City or Town)
(Zip Code)
NOTE: The DSS-1800 is prepared in triplicate. The original form is held in the Office of the Clerk of Superior Court. A duplicate original
is forwarded, along with originals of all other documents filed in proceeding, within ten days following the entry of the Decree of
Adoption by the Clerk of Court to the Division of Social Services, State Department of Health and Human Services; and a copy is
attached to the Order for a Report to the Court, directed to the county department of social services or licensed private child-placing
agency.
DSS-1800 (Rev. 11/2014)
Child Welfare Services
Page 3 of 3
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