Form DSS-5169 "Consent of Child for Adoption" - North Carolina

What Is Form DSS-5169?

This is a legal form that was released by the North Carolina Department of Health and Human Services - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2014;
  • The latest edition provided by the North Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DSS-5169 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DSS-5169 "Consent of Child for Adoption" - North Carolina

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STATE OF NORTH CAROLINA
__________________ COUNTY
CONSENT OF CHILD FOR ADOPTION
(Stepparent Adoption)
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.
_________________________________________________
Signature – Adoptee’s Original Name
_________________________________________________
Address
DSS-5169 (Rev. 11/2014)
Child Welfare Services
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STATE OF NORTH CAROLINA
__________________ COUNTY
CONSENT OF CHILD FOR ADOPTION
(Stepparent Adoption)
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.
_________________________________________________
Signature – Adoptee’s Original Name
_________________________________________________
Address
DSS-5169 (Rev. 11/2014)
Child Welfare Services
Page 1 of 2
STATE OF NORTH CAROLINA
__________________ COUNTY
I, _________________________________________________________________, do hereby certify that
(Name of Official)
_____________________________________________________ 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)
Signature _________________________________
(SEAL)
Title _____________________________________
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.
DSS-5169 (Rev. 11/2014)
Child Welfare Services
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