Fillable 700 00139B Consent Of Guardian Or Agency (Vermont Judiciary)

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700 00139B Consent Of Guardian Or Agency (Vermont Judiciary)

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700-00139B - Consent of Guardian or Agency to Adoption (Stepparent or Partner Adoption) (04/2017) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of:
CONSENT OF GUARDIAN OR AGENCY TO ADOPTION
(Stepparent or Partner Adoption)
I swear or affirm under oath that the facts set forth below are true and I consent to the adoption of the minor
child named below.
Information about Guardian or Representative of Agency signing the Consent:
My Name: _________________________________________ Date of Birth: _____________________________
Address: __________________________________________ Email Address: ____________________________
City/State/Zip: _____________________________________ Daytime Phone: ___________________________
Name of Attorney: ____________________________________________________________________________
Address of Attorney: ________________________________ City/State/Zip: ____________________________
Information about the Minor to be Adopted:
Minor’s Name: _____________________________________ Date of Birth: _____________________________
Information about the Attorney Who Represents the Prospective Adoptive Parents:
Name of Attorney: __________________________________ Phone: __________________________________
Address: __________________________________________ City/State/Zip: ____________________________
I am: (Check One Box Only)
☐ the Guardian of this minor and my consent is required for his/her adoption.
☐ a duly authorized representative of an agency whose consent is required for the adoption of this
minor.
Information about the agency is as follows:
Name of Agency: _____________________________________ Phone: _____________________________
Address: ___________________________________________ City/State/Zip: _______________________
I,
or my agency, obtained the authority to consent to the adoption in the following manner: (Describe)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
700-00139B - Consent of Guardian or Agency to Adoption (Stepparent or Partner Adoption) (04/2017) Page 2 of 2
Agreements
I understand and agree that: (Check All That Apply)
☐ The adoption will not terminate the parental relationship between the minor and the parent who is
living with the stepparent.
☐ The adoption will terminate the parental relationship between the minor and the parent who is not
living with the stepparent.
☐ The adoption will terminate any existing court order for custody, visitation or communication with the
minor.
☐ Notwithstanding the adoption:
A. The minor and any descendant of the minor will retain rights of inheritance from and
through the parent of the minor who is not living with the stepparent; and
B. A court order for parent child contact (visitation or communication) with the minor by either
parent, or by a person related to the minor through either parent, 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 terms of the order or agreement is not a
ground for revoking or setting aside this consent or the adoption; and
C. The parent who is not living with the stepparent remains liable for arrearages of child support
unless relieved of that obligation by the parent who lives with the stepparent, and any guardian
ad litem of the minor and by a governmental agency providing public assistance to the minor.
Waiver of Notice: (Check One Box Only)
☐ I waive notice to me or to my agency of any further proceedings in the adoption of the minor child
unless the adoption is contested, appealed, or denied.
☐ I do not waive notice to me or to my agency of any further proceedings in the adoption of
the minor child.
Voluntary Consent:
I state for myself or on behalf of my agency that I voluntarily and unequivocally consent to the adoption
of this minor child.
I swear or affirm that the facts set forth in this consent are true and correct to the best of my knowledge and
belief.
Date
At:
Signature
City, County and State
Printed Name
Signed and confirmed in the presence of the Judge or in the presence of a person directed by the Judge
Date
Signature
Printed Name of Judge or Other Person Authorized by Judge
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700 00139B Consent Of Guardian Or Agency (Vermont Judiciary)

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Completed 15 July 2020

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