Consent To Adoption {139G}

10/04 SMLFORM 139G. CONSENT TO ADOPTIONSTATE OF VERMONT PROBATE COURT DISTRICT OF , SS. Docket No. IN RE THE ADOPTION OF , A MINOR of CONSENT TO ADOPTION 15A V.S.A. 247 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 setforth 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; [ ] singleand 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 birthwas (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) andaddress is as follows (Please give the names, addresses and telephone numbers, if available, or ifunavailable 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: American LegalNet, Inc. www.FormsWorkFlow.com (4) I am voluntarily and unequivocally consenting to the transfer of legal and physicalcustody to, and adoption of, the above-named minor child by the proposed adoptiveparent(s) who I have selected and who are identified in paragraph #3 above. I furtherbelieve 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 daysafter this consent is executed that I wish to revoke this consent. (I understand that if I and theprospective parents agree, we may jointly revoke this consent anytime before finalization of theadoption. 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 thisconsent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days afterthe minor was placed for adoption without good cause, then I may petition the court to have thisconsent revoked. The petition may be filed in the court in which the adoption is pending, ifknown, 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 befiled, is: .If unknown, the name and address of the court in which a motion to set aside this consent on thebasis 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. 247 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 ofadoption. I understand that, unless otherwise provided in this consent, my signing of this consentand failure to revoke the consent terminates any right I may have to object to the minor'sadoption by the prospective adoptive parent(s). I also have been informed about theconsequences of misidentifying the other parent of this child and the procedure for releasinginformation 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 theadoptive parent or the adoption agency to which the child is being relinquished; the name of theattorney is and he or she is present as this consent is beingexecuted; (g) If I am an adult, I certify that I was informed of my right to have an attorney represent me inthis matter who is not representing the adoptive parent or representing the adoption agency towhich the child is being relinquished; (h) I have provided to the adoptive parents, or their agent, nonidentifying information andinformation about the child's and my family's health history and background as required by 15AV.S.A. 247 2-105, and I understand that before the adoption becomes final, if information becomesavailable to me which was unavailable previously, then I have an obligation to provide thisinformation; (i) I have been made aware that it is in the best interests of the adoptee that I keep the court orthe adoption agency informed of my current address and any family health problems of minewhich may develop which could affect the child so that the court or agency may respond to anyinquiry concerning the adoptee's medical or social history. I have also been made aware of theprocedure for releasing information about the health and other characteristics of the parent whichmay affect the physical or psychological well-being of the adoptee and the procedure for releaseof the parent's identity pursuant to Article 6 of the Vermont Adoption Act. American LegalNet, Inc. www.FormsWorkFlow.com (j) I have not received or been promised any money, or anything of value, in exchange for myexecuting this consent except for payments which are authorized under 15A V.S.A. 247 7-103 andwhich are itemized on an attachment to this consent; I (circle one) have/have not been a recipientof public assistance during the last 12 months; (k) The minor child (circle one) is/is not an Indian Child as defined in the Indian Child WelfareAct, 25 U.S.C. 247 1901 et seq. (l ) That I (choose one) [ ] waive notice of any proceeding for adoption of the adoptee; [ ] waive notice of the adoption unless the adoption is contested, appealed or denied; [ ] do not waive notice of any proceeding for adoption and I would like to be notified at myaddress as set forth above; (m) I understand that the adoption will make any orders or agreements for visitation orcommunication with the minor unenforceable; (n) I understand that after this consent has been executed in compliance with 247 2-405 and notrevoked in compliance with 247 2-408 or 247 2-409, then the consent becomes final and may not berevoked or set aside for any reason, including the failure of the adoptive parent or agency topermit me to visit or communicate with the minor adoptee. I further understand that this consentwill extinguish all parental rights and obligations, and the adoption will completely terminate every aspect of the legal relationship which I may have concerning the minor, except forarrearages of child support. (o) That before executing this consent I was informed of the availability of personal counselingby a certified adoption counselor, or other counselor of my choice and legal counseling. (8) If this consent is being made conditional upon other conditions which are authorized under15A V.S.A. 247 2-406(e), that those conditions are set forth with particularity here. (If none, sostate.) (9) I (circle one) have/have not participated as a party, witness, or in any other capacity in anylitigation or action concerning the custody or support of the above-named minor in Vermont orany other state. I (circle one) have/have no knowledge of any person or adoption agency or stateagency who has physical or legal custody of the child, or who claims to have custody orvisitation rights with this child. (Any affirmative answer in this paragraph requires a descriptionof the action or claim, including the court and docket number if available.) I swear that the factual information set forth in this consent is true and correct to the best of myknowledge and belief. Dated this day of , , at , County of , and State of . (signature) (typed or printed name) American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION The Consent to Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. 2472-405. Those facts set forth in the consent were sworn to, under oath or affirmation, and I herebycertify that I explained to the person executing the consent th