Consent of Child for Stepparent Adoption

CONSENT OF CHILD FOR ADOPTION (Stepparent Adoption)

DSS-5169 (Rev. 11/2014)

Child Welfare Services

Page 1 of 2

STATE OF NORTH CAROLINA

__________________ COUNTY

I, , being duly sworn, declare:

1. That I was born on the day of , , that my present address is

2. By executing this document, I am voluntarily consenting to my adoption by

(Full name of petitioning stepparent)

3. That I understand that my Consent may be revoked at any time before the Decree of Adoption is entered by filing written notice with the Court in which the adoption petition is pending, which is

4. That the Consent shall be valid and binding and is not affected by any oral or separate written agreement between myself and the adoptive parent(s);

5. That in relation to my adoption, I have not received or been promised any money or anything of value for my Consent;

6. That I understand that the adoption will not terminate the legal relationship of parent and child between myself and my parent, , who is the stepparent’s spouse.

(Name)

I further understand that the adoption will terminate the legal relationship of parent and child between myself and my parent, , who is not the stepparent’s spouse,

(Name)

including all my rights to inherit from or through that parent, and will extinguish any court order of custody, visitation, or communication with me, except that such parent’s obligation for past due child support payments will remain unless legally released from that obligation; and,

7. That I have read or had read to me and understand this Consent; been advised that counseling services may be available through the county department of social services or a licensed child-placing agency; and been advised of my right to consult with any legal counsel already appointed for me.

DSS-5169 (Rev. 11/2014)

Child Welfare Services

Page 2 of 2

STATE OF NORTH CAROLINA

__________________ COUNTY

I, , do hereby certify that

personally appeared before me this day

(Original Name of Adoptee)

and acknowledged the due execution of the foregoing document and that this document has been sworn to (or affirmed) and subscribed before me. I further certify to the best of my knowledge and belief that the adoptee executing the Consent: read, or had read to him or her, and understood the Consent, signed the Consent voluntarily; received an original or a copy of his or her 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 administer oaths or take acknowledgements.

Witness my hand and seal this the day of

at

(Place of Consent)

My commission expires

Note:

Form DSS-5169 is prepared in duplicate and is to be signed by the child being adopted who is twelve years of age or over when the Petition for Adoption is filed or who becomes twelve years of age before the granting of the Decree of Adoption. The original form is presented to the Clerk of Superior Court who then forwards it with the Petition and other Consents/Relinquishments to the Division of Social Services, State Department of Health and Human Services. A signed copy is given to the adoptee.