Vermont > Statewide > Probate Court
Consent Of Partner (To Adoption) 139H - Vermont
| Consent Of Partner (To Adoption) Form. This is a Vermont form and can be used in Probate Court Statewide . |
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Probate Court Form No. 139h Consent of Partner (Page 1 of 2) STATE OF VERMONT PROBATE COURT DISTRICT OF _______________________ IN RE ADOPTION OF ______________________ DOCKET NO. _________________ CONSENT OF PARTNER 15A V. S. A. 4-104 1. My Full Name ___________________________________ 2. My Mailing Address ______________________________ ______________________________ ______________________________ 3. My Date of Birth __________________________________ 4. Full Name of Minor Who Is Being Adopted __________________________________ 5. Date of Birth of Minor Who Is Being Adopted ________________________________ 6. Full Name, Address and Telephone Number of the Attorney Representing the Prospective Adoptive Parent(s) With Whom I have Placed, or Intend to Place My Minor Child for Adoption: _______________________________________ _______________________________________ _______________________________________ 7. I state that I have legal and physical custodyof m y above-named minor child. I voluntarily and unequivocally consent to the adoption of my said minor child. 8. I understand and agree that the adoption will not term the relationship between minate y minor child and me. 9. I understand and agree that the adoption will term the relationship of parent and inate child between my minor child and the minor childs other parent. 10. I understand and agree that the adoption will terminate any existing court order for custody, visitation, or communication with the minor child. 11. I understand and agree that notwithstanding the adoption: A. the minor and any descendant of the minor will retain rights of inheritance from and through the minors other parent; B. a court order for visitation or communication with the minor by me, or by a person related to the minor through me, or an agreement or order concerning another person which is approved by the court under 15A V. S. A. 4-112, survives the decree of adoption, but failure to comply with the rmte s of the order or agreement is not a ground for revoking or setting aside this consent or the adoption; C. the other parent remains liable for arrearage child support unless relieved of that obligation by me, and any guardian ad litem of the minor and by the governmental agency providing public assistance to the minor. <<<<<<<<<********>>>>>>>>>>>>> 2Probate Court Form 139h Consent of Partner (Page 2 of 2) 12. This consent is not, and cannot be, a waiver of any further notice to me of the proceeding for adoption of the minor child by the person seeking to adopt. 13. I swear that the factual informtion a set forth in this consent is true and correct to the best of my knowledge and belief. Dated: __________________________ Signed _____________________________ Print Name: _________________________ Address: ____________________________ ____________________________________ Telephone: (____) ____________________STATE OF VERMONT COUNTY OF _______________________ On the _____ day of ____________________ 20___, ___________________________________ personally appeared before me and signed or confirmd in emy presence that he or she freely and voluntarilysigned the above consent and acknowledged that the factual information set forth therein is true and correctto the best of his or her knowledge and belief. I am one of the following: _____ a Judge of a court that has jurisdiction ov adoption proceedinger s in the State of Vermont; _____ a person appointed by a Probate Judgto take e consents or relinquishments; _____ a commissioned officer on active duty in the military service of the United States and the person signing the consent is in the military service; _____ an officer of the foreign service or a consular officer of the United States in another country, to wit: _________________________________, and the person executing this consent appeared before me in that country; _____ a person authorized to take acknowledgments. _____________________________ (Signature) _____________________________ (Printed Name)
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