STATE OF NORTH CAROLINA
COUNTY
(Full name of petitioning parent 1)
(Full name of petitioning parent 2)
FOR THE ADOPTION OF
(Full name by which adult adoptee is to be known if adoption granted)
IN THE GENERAL COURT OF JUSTICE
DISTRICT COURT DIVISION BEFORE THE CLERK
SP
PETITION FOR
ADULT ADOPTION
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To the Honorable, Clerk of the Superior Court of |
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____________________County: |
We (1), the undersigned, |
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(Name of petitioning parent 1) |
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(Sex) |
(Marital Status) |
and/or |
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whose address is |
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(Name of petitioning parent 2) |
(Sex) |
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(Marital Status) |
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(Street & Number) |
(RFD) |
(City) |
(County) |
(State) |
do hereby petition the Court for leave to adopt
(Name by which the adoptee is to be known)
, an adult, pursuant to N.C.G.S. 48-5-100, et. seq., and represent to the Court:
(Sex)
1.That the petitioner(s) herein seeking adoption
has/have lived in or been domiciled in North Carolina for at
least six consecutive months immediately preceding the filing of this petition; or
the adoptee has lived in North Carolina for at least six consecutive months immediately preceding the filing of this petition or from birth.
2. |
That |
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was born in the State/Country of |
(Original Name of Adult Adoptee)
3.That the petitioner(s) is/are [related] [not related] to the said adult adoptee in the following manner:
_________________________________________________________________________________________
4.That the following are the name, age, and last known address of any adult child of the prospective adoptive parent, including an adult previously adopted by the prospective adoptive parent or the adoptive parent's spouse, and the date and place of the adoption:
_________________________________________________________________________________________
5.That the following are the name, age, and last known address of any living parent, spouse, or adult child of adoptee:
_________________________________________________________________________________________
DSS-5163 (Rev. 11/2014)
Child Welfare Services
Page 1 of 2
6.That the following is a description and estimate of the value of any property of the adoptee, if adjudicated incompetent:
_________________________________________________________________________________________
7.That the adoptee’s true name as it appears on his/her birth certificate is:
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_________________________________________________________________________________________ |
8. |
That the adoptee is presently married to |
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, having been |
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married on or about the |
____day of |
__________I ____________ |
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WHEREFORE, your petitioner(s) pray(s) that the relationship of parent and child be established between petitioner(s) and said adult and that the adult adoptee's name [remain] [be changed to]
_________________________________________________________________________________________
__________________________________________________________________pursuant to G. S. 48-9-102 (g).
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This the |
day of |
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___________________________________Signature of Petitioner 1 |
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__________________________________ Signature of Petitioner 2 |
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ACKNOWLEDGMENT |
, being duly sworn, deposes and says that he/she has read the foregoing Petition and that the facts set forth therein are true to his/her knowledge, except as to matters therein set forth upon information and belief,, and as to those such matters he/she believes them to be true.
__________________________________Signature of Petitioner 1
__________________________________Signature of Petitioner 2
Subscribed and sworn to before me this |
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day of |
(S E A L)
Clerk Superior Court or Notary Public
My commission expires:
________________________________________________________________________________________________
Attorney for petitioner/s(Mailing Address)
_________________________________________________________________________________________________
(Telephone Number) |
(City or Town) |
NOTE: The DSS-5163 is prepared in duplicate. The original form is held in the Office of the Clerk of Superior Court. A copy is forwarded, along with originals of all other documents filed in proceeding, within ten days following the entry of the Decree of Adoption by the Clerk of Court to the Division of Social Services, State Department of Health and Human Services.
DSS-5163 (Rev. 11/2014)
Child Welfare Services
Page 2 of 2