AOC-SP-164 — Minor Child's Consent to Own Adoption

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01 ATTORNEY / GUARDIAN AD LITEM INFORMATION

Attorney Name *

State Bar No. *

Firm / Office Name

Address *

Phone *

Fax

Email *

Role

02 CHILD INFORMATION

Child's Full Legal Name *

Date of Birth *

County *

⚠ Child must be age 12 or older at time of hearing to execute this consent

Current Address *

Adoption Case File Number *

03 PROSPECTIVE ADOPTIVE PARENT(S)

Adoptive Parent / Petitioner 1 Name *

Adoptive Parent / Petitioner 2 Name (optional — joint petition)

Relationship of Petitioner(s) to Child

04 CHILD'S STATEMENT OF CONSENT

Child's Personal Statement of Consent *

Attorney / GAL Represented

05 JUDICIAL OFFICER

Judge or Magistrate Name *

Courthouse

Date of Hearing *

06 WITNESSES

Witness 1 Name *

Witness 1 Signature

Witness 2 Name

Witness 2 Signature

07 NOTARY BLOCK

Notary County

Notary Name

Commission Expiration

SELECTED COUNTY

— Select above —

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KEY LEGAL RULES

Child must be age 12 or older at time of hearing
Court must find consent is freely and voluntarily given
Child may withdraw consent until adoption order is entered
Written consent cannot be waived by the court
Consent signed before judge, clerk, or notary
Court may interview child privately to confirm voluntariness
If child has special needs or cognitive limitations, attorney/GAL strongly recommended

STATUTORY REFERENCE

G.S. 48-3-601(b)Required if age 12+

G.S. 48-3-606Execution requirements

G.S. 48-3-607Withdrawal of consent

AOC-SP-164Current revision

NEED AN ATTORNEY?

Barker Richardson, PLLC handles adoption matters in NC
GAL representation strongly recommended for this form
Contact: lawvana.com