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_________________________________________________________________________________________; I do not have a permanent address, but do have a mailing 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 _____________________________________________
(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);
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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;
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
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STATE OF NORTH CAROLINA
____________________COUNTY
I, ____________________________________________________________________________, do hereby certify
(Name of official)
that __________________________________________________________ personally appeared before me this day
Name of [Mother] [Father] [Guardian Ad Litem of the Mother/Father] [Guardian]
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 parent or guardian 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 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 acknowledgments.
Witness my hand and seal this the ___________ day of ____________________________________, ___________,
at_________________________________________________________________________________________
(Place of Consent)
Signature____________________________________
Title_____________________________________
(S E A L)
My commission expires _______________________________
Note:
The original Consent to Adoption by Parent, Guardian Ad Litem of the Mother/Father, or Guardian of the child 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.
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