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Consent To Adoption 139G - Vermont
| Consent To Adoption Form. This is a Vermont form and can be used in Probate Court Statewide . |
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FORM 139G. CONSENT TO ADOPTION STATE OF VERMONT DISTRICT OF ______________, SS. PROBATE COURT Docket No. _____________ IN RE THE ADOPTION OF ___________________________________________, A MINOR of ____________________________ CONSENT TO ADOPTION 15A V.S.A. § 2-406 NOW COMES the undersigned person, ______________, and does swear or affirm under oath to the facts set forth herein and does consent to the adoption described herein as set forth in more detail below: (1) My full name is __________________________________; my date of birth is ________ __________________; my current mailing address is ________________________________ ______________________; I am (check one) [ ] married [ ] single and never married; [ ] single and divorced. (2) The full name of the minor to be adopted is ______________________________________: (circle one) his or her date of birth is ______________________________ and the time of birth was ____________ (A.M./P.M.). The minor is currently living at the following address: ______________________________________________________________________________ ______________, and has lived there for ____________ (weeks, months or year). (3a) The name and address of the adoptive parents are known to me and their name(s) and address is as follows (Please give the names, addresses and telephone numbers, if available, or if unavailable or unknown to you, please give whatever information you have): _____________________________________________________________________________ _____________________________________________________________________________ The name of the attorney representing the prospective adoptive parent(s) is: ________________ ________________________________ and his or her address and telephone number is: ____________________________________________________________________________ (3b) The full name and address of the other parent is: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ The date of birth of the other parent is _______________________________; the other parent is (check one) [ ] married; [ ] single and never married; [ ] single and divorced. If the full name and address is not provided, please state the reason: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 10/04 SML American LegalNet, Inc. www.FormsWorkflow.com (4) I am voluntarily and unequivocally consenting to the transfer of legal and physical custody to, and adoption of, the above-named minor child by the proposed adoptive parent(s) who I have selected and who are identified in paragraph #3 above. I further believe that the adoption of the minor is in the minor's best interest. (5) I understand that I may revoke this consent by notifying the court in writing within 21 days after this consent is executed that I wish to revoke this consent. (I understand that if I and the prospective parents agree, we may jointly revoke this consent anytime before finalization of the adoption. If the prospective adoptive parents do not agree to revoke after the 21 day period then the consent becomes irrevocable on the 22nd day after its execution.) I understand that if this consent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days after the minor was placed for adoption without good cause, then I may petition the court to have this consent revoked. The petition may be filed in the court in which the adoption is pending, if known, or in the court in which this consent is signed. (6) The name and address of the court in which the adoption petition has been filed, or will be filed, is: _____________________________________________________________________. If unknown, the name and address of the court in which a motion to set aside this consent on the basis of fraud, duress or otherwise, would be filed in: __________________________________ ________________________________ District Probate Court located at __________________ ________________________________________. (7) I certify to the following: (a) I have read this consent, or I have had it read to me; (b) English is my native language (if not, see 15A V.S.A. § 2-406(a)); (c) I am signing this consent voluntarily; (d) I have received a copy of this consent; (e) Before signing this consent, I have been informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this consent, my signing of this consent and failure to revoke the consent terminates any right I may have to object to the minor's adoption by the prospective adoptive parent(s). I also have been informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee; (f) If I am a minor, I certify that I was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is __________________________ and he or she is present as this consent is being executed; (g) If I am an adult, I certify that I was informed of my right to have an attorney represent me in this matter who is not representing the adoptive parent or representing the adoption agency to which the child is being relinquished; (h) I have provided to the adoptive parents, or their agent, nonidentifying information and information about the child's and my family's health history and background as required by 15A V.S.A. § 2-105, and I understand that before the adoption becomes final, if information becomes available to me which was unavailable previously, then I have an obligation to provide this information; (i) I have been made aware that it is in the best interests of the adoptee that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop which could affect the child so that the court or agency may respond to any inquiry concerning the adoptee's medical or social history. I have also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may a
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