700-00139A – Consent of Non-Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) (04/2017) Page 2 of 3
☐ I am an adult and I certify that I was informed of my right to have an attorney represent me in this
matter, specifically an attorney who is not representing the adoptive parent or the adoption agency to
which the child is being relinquished; (Do Not Check This Box if You are a Minor)
☐ Before executing this Consent, I was informed of the availability of personal counseling by a certified
adoption counselor or other counselor of my choice.
☐ I have been informed about the consequences of misidentifying the other parent of this child.
☐ I have been advised of my obligation to provide information concerning disclosure of background
information about the minor, the minor’s parents and the extended family.
☐ I have provided the person seeking to adopt my child with non-identifying information about the
child’s and my family’s health history and background as required by law (15A V.S.A. §2-105). I
understand that before the adoption becomes final, if information becomes available to me which was
previously unavailable, then I have an obligation to provide this information.
☐ I have been informed of the procedure for releasing information about the health and other
characteristics of the parent which may affect the physical or psychological well-being of the minor.
☐ I have been informed about the procedures for release of a parent’s identity pursuant to Article 6 of
15A V.S.A.
☐ I have been informed that it is in the best interests of the minor child that I keep the court informed of
my current address and any family health problems which may develop and which could affect the
child. This will allow the court to respond to any inquiries concerning the minor’s medical or social
history.
☐ I have not received or been promised any money, or anything of value, in exchange for my executing
this consent except for payments which are authorized by law (15A V.S.A. §7-103). These payments
are itemized on an attachment to this consent.
☐ The minor child is an Indian child as defined by the federal Indian Child Welfare Act.
☐ I understand and agree that the adoption will terminate my parental relationship to the minor child
and will terminate any existing court order for custody, visitation, or communication with the minor
child. Notwithstanding the adoption, I agree that:
☐ The minor and any descendant of the minor will retain rights of inheritance from and through myself.
☐ The court may approve an agreement for visitation or communication with the minor after the
adoption if the court determines the agreement is in the best interests of the minor. Failure comply
with the agreement is not grounds for revoking the consent or setting aside the adoption.
☐ I will remain liable for arrearages of child support, unless released from that obligation by the other
parent and/or a governmental agency providing financial assistance for the support of the minor.