Fillable Consent Of Parent Who Is Not Stepparent’s Spouse (Non-Custodial Biological Parent) (Vermont Judiciary)

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Consent Of Parent Who Is Not Stepparent’s Spouse (Non-Custodial Biological Parent) (Vermont Judiciary)

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700-00139A – Consent of Non-Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) (04/2017) Page 1 of 3
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of:
CONSENT OF NON-CUSTODIAL BIOLOGICAL PARENT TO ADOPTION
(Stepparent or Partner Adoption)
15A V.S A. § 4-105
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 Non-Custodial Biological Parent 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 certify that the following statements are true: (Check the Box if the Statement is True. Leave the Box Empty, if the
Statement is Not True.)
☐ I have read this consent or I have had it read to me.
☐ I have been informed about the meaning and consequences of adoption.
☐ I understand that the adoption will terminate completely every aspect of the legal relationship I have
with the minor child except for arrearages of child support.
☐ I understand that the adoption will remain valid whether or not any agreement for visitation or
communication with the minor is later performed.
☐ I am a minor and I certify that I was advised by an attorney who is not representing the adoptive
parent(s) or the adoption agency to which the child is being relinquished. The name of the attorney
who gave me advice is _________________________ and he or she is present as this consent is being
executed. (Do Not Check This Box if You are an Adult)
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.
700-00139A – Consent of Non-Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) (04/2017) Page 3 of 3
With respect to notice of further proceedings related to this adoption: (Check One Box Only)
☐ I waive notice of any proceeding for adoption of the minor;
☐ I waive notice of the adoption unless the adoption is contested, appealed or denied;
☐ I do not waive notice of the proceedings related to this adoption. I would like to be notified at the
address in paragraph 1 of this Consent.
Voluntary Consent:
I voluntarily and unequivocally consent to the adoption of my minor child by the person who is seeking
to adopt and to the transfer to that person, and his or her present spouse, any right I have to legal or
physical custody.
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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Consent Of Parent Who Is Not Stepparents Spouse (Non-Custodial Biological Parent) (Vermont Judiciary)

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Completed 15 July 2020

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