Form DSS-5189 "Consent to Adoption by Parent Who Is Spouse of Stepparent (Stepparent Adoption)" - North Carolina

What Is Form DSS-5189?

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-5189 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-5189 "Consent to Adoption by Parent Who Is Spouse of Stepparent (Stepparent Adoption)" - North Carolina

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STATE OF NORTH CAROLINA
COUNTY
CONSENT TO ADOPTION
BY PARENT WHO IS SPOUSE OF STEPPARENT
(STEPPARENT ADOPTION)
I, ______________________________________________________________________________________, declare:
1.
That I was born on the _________ day of __________________, _________, and have a permanent address at
_______________________________________________________________________________________________;
2.
That I am of sound mind and in full possession of my mental faculties;
3.
That I am the [mother] [father] of _______________________________________________, a __________
(Original Name of Child)
(Sex)
child, born on the ________day of ____________________, ______, in _____________________________________
(City or Town)
(County)
_______________________;
(State/Country)
4.
That I have legal and physical custody of the adoptee, and the child has resided primarily with me and his/her
stepparent since _________________________, ___________;
5.
That I hereby voluntarily consent to the adoption of said child by his/her stepparent, ____________________
________________________________________________________, who is my spouse;
(Full name of petitioning stepparent)
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 parent;
7.
That I understand that when the adoption is final, the legal relation of parent and child between adoptee and the
adoptee's birth or prior adoptive [mother] [father] will be terminated, including all rights of the adoptee to inherit as a
child from and through _______________________________________________________________, and that the
adoption
(Full name of birth or prior adoptive mother/father)
will extinguish any existing court order of custody, visitation, or communication with the adoptee, except that
__________________________________________________________________ will remain liable for past due child
(Full name of birth or prior adoptive mother/father)
support payments unless legally released from this obligation;
8.
That I understand that the adoption will not terminate the legal relation of parent and child between myself
and the adoptee;
9.
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;
DSS-5189 (Rev. 11/2014)
Child Welfare Services
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STATE OF NORTH CAROLINA
COUNTY
CONSENT TO ADOPTION
BY PARENT WHO IS SPOUSE OF STEPPARENT
(STEPPARENT ADOPTION)
I, ______________________________________________________________________________________, declare:
1.
That I was born on the _________ day of __________________, _________, and have a permanent address at
_______________________________________________________________________________________________;
2.
That I am of sound mind and in full possession of my mental faculties;
3.
That I am the [mother] [father] of _______________________________________________, a __________
(Original Name of Child)
(Sex)
child, born on the ________day of ____________________, ______, in _____________________________________
(City or Town)
(County)
_______________________;
(State/Country)
4.
That I have legal and physical custody of the adoptee, and the child has resided primarily with me and his/her
stepparent since _________________________, ___________;
5.
That I hereby voluntarily consent to the adoption of said child by his/her stepparent, ____________________
________________________________________________________, who is my spouse;
(Full name of petitioning stepparent)
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 parent;
7.
That I understand that when the adoption is final, the legal relation of parent and child between adoptee and the
adoptee's birth or prior adoptive [mother] [father] will be terminated, including all rights of the adoptee to inherit as a
child from and through _______________________________________________________________, and that the
adoption
(Full name of birth or prior adoptive mother/father)
will extinguish any existing court order of custody, visitation, or communication with the adoptee, except that
__________________________________________________________________ will remain liable for past due child
(Full name of birth or prior adoptive mother/father)
support payments unless legally released from this obligation;
8.
That I understand that the adoption will not terminate the legal relation of parent and child between myself
and the adoptee;
9.
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;
DSS-5189 (Rev. 11/2014)
Child Welfare Services
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10.
That I hereby waive notice of any proceeding for adoption;
11.
That I have read or had read to me and understand 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 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.
15.
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.
16.
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]
____________________________________________________
Address
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Child Welfare Services
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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]
and acknowledged the due execution of the foregoing document. I further certify to the best of my knowledge and belief
that the parent 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 the 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 acknowledge signatures under
Chapter 47 of the General Statutes of North Carolina.
Witness my hand and seal this the ___________ day of ______________________________________, ___________,
at _____________________________________________________________________________________________
(Place of Consent)
Signature _____________________________________
(S E A L)
Title
_____________________________________
My commission expires _______________________________
Note:
The original Consent to Adoption by Parent Who is Spouse of Stepparent 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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