CONSENT OF CUSTODIAL BIOLOGICAL PARENT TO ADOPTION
(Stepparent or Partner Adoption)
15A V.S A. §4-104
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 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: ____________________________
Agreements:
I understand and agree that: (Check All That Apply)
☐ The adoption will not terminate the parental relationship between the minor and me.
☐ The adoption will terminate the parental relationship between the minor and the other parent of the
minor.
☐ The adoption will terminate any existing court order for custody (parental rights and responsibilities),
visitation (parent child contact) or communication with the minor.
☐ The adoption does not terminate the following rights and obligations:
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 approved agreement for visitation or communication with the minor after the adoption if
the court determines that the agreement is in the best interests of the child. Failure to comply
with the court ordered agreement is not grounds for revoking consent or setting aside the
adoption; and
