North Carolina Affidavit of Parentage

STATE OF NORTH CAROLINA
____________________COUNTY
AFFIDAVIT OF PARENTAGE
I, the undersigned, _____________________________________________________________, being duly sworn,
[Mother] [Father] [Guardian] [Other Knowledgeable Individual]
declare the following persons to be the parents or possible parents of _______________________________________,
(Original Name of Child)
a minor ____________child, who was born on the ___________ day of ___________________________, _________,
(Sex)
[or expected to be born approximately __________________________] in __________________________________
(City or Town)
____________________________________________________.
(County)
(State)
Mother:
_____________________________________________
(Name)
_______________________________________
(Marital status at time of child's birth)
_______________________________________________________________________________________
(Last known address)
Biological
Father: _____________________________________________
(Name)
_______________________________________
(Marital status at time of child's birth)
_______________________________________________________________________________________
(Last known address)
(If more than one possible)
Biological
Father: _____________________________________________ _______________________________________
(Name)
(Marital status at time of child's birth)
_______________________________________________________________________________________
(Last known address)
Legal
Father:
_____________________________________________
(Name)
_______________________________________
(Marital status at time of child's birth)
_______________________________________________________________________________________
(Last known address)
DSS-1809 (Rev. 1/2003)
Children's Services
Source of my knowledge (if not signed by placing parent or guardian): _____________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
FURTHER, it is the intent of the undersigned to place the above-named child for adoption in accordance with Chapter
48 of the General Statutes of North Carolina.
____________________________________________________
Signature of (Mother) (Father) (Guardian)
(Other Knowledgeable Individual)
STATE OF ______________________________
COUNTY OF ____________________________
I, _______________________________________________________________________________, do hereby certify
(Name of official)
that ____________________________________________________________ personally appeared before me this day
(Name of parent or guardian)
and acknowledged the due execution of the foregoing instrument.
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 __________________________________, ____________.
Signature _____________________________________
(S E A L)
Title
_____________________________________
My commission expires _______________________________
NOTE:
One Form DSS-1809 is obtained at the time the Consent to Adoption by Parent, Guardian Ad Litem, or Guardian
(DSS-1802) or Relinquishment to Adoption (DSS-1804) is signed. This Affidavit of Parentage and the Consent or
Relinquishment are filed with the Clerk of Superior Court at the time the Petition for Adoption is filed. The Clerk then
forwards these documents to the Division of Social Services, State Department of Health and Human Services.
G.S. 48-3-206 provides that in the event the placing parent or guardian is unavailable, this information may be provided
by another knowledgeable individual who should then sign this form and indicate the source of his knowledge. This
affidavit is not necessary when an agency acquires legal and physical custody of a minor for adoption by court order
terminiating the parental rights of the parent or guardian.