STATE OF NORTH CAROLINA
COUNTY
CONSENT TO ADOPTION
BY PARENT, GUARDIAN AD LITEM, OR GUARDIAN
I, ______________________________________________________________________, being duly sworn, 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] or [ __________ ] of ___________________________________________,
(Original name of child)
a ______ child, born on the ________day of ___________________, _______, [or expected to be born approximately
(Sex)
______________________ ] in _____________________________________________________________________.
(City or Town)
(County)
(State)
4.
That I hereby consent to the adoption of said child by _____________________________________________
(Full name of petitioning father)
and ___________________________________________________;
(Full name of petitioning mother)
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 requir