Fillable Form 700 00128 (Vermont Judiciary)

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Form 700 00128 (Vermont Judiciary)

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700-00128 – Relinquishment of Minor to Agency for Adoption (07/2016) Page 1 of 4
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION
I swear or affirm under oath that the facts set forth below are true and I voluntarily relinquish my child for
adoption.
My Information:
Full Name: ______________________________________________________________________
Date of Birth: _____________________________ Place of Birth: ____________________________
Mailing Address (town, state, zip): ______________________________________________________________
Phone Number: _____________________________
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
My native language is: ☐ English ☐ Other (specify) _______________________________
Information about the Minor Child to be Adopted:
Minor’s Full Name: ______________________________________________________________________
Date of Birth: _____________________________ Time of Birth: ____________________________
Name of Person(s) with Whom Minor Resides: __________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Minor has lived at this address for ________ ☐ Weeks ☐ Months ☐ Years
My relationship to this child is ☐ Parent ☐ Legal Guardian ☐ Other ____________
I have authority to relinquish this child for adoption ☐ Yes ☐ No
Information about the Other Parent: provide all information that you know about
Name of Other Parent: ____________________________________________________________________
Other Parent’s Date of Birth: ___________________________
Mailing Address (town, state, zip): ______________________________________________________________
Phone Number: _____________________________
Marital Status: ☐ Married ☐ Never Married ☐ Divorced ☐ Don’t Know
I do not know some or all of the information about the other parent because:
______________________________________________________________________________________
______________________________________________________________________________________
Information about the adoption agency:
Name(s) of Agency: ____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Phone Number: _____________________________
700-00128 – Relinquishment of Minor to Agency for Adoption (07/2016) Page 2 of 4
1. Voluntary Consent:
After careful consideration, I believe that it is in the best interests of my child to be placed for adoption.
I voluntarily and unequivocally consent to the transfer of legal and physical custody of this minor child
to the above named adoption agency for the purposes of adoption and to take any and all measures
that may be in the best interests of the child.
2. Revocation of Consent:
I understand that:
a) I may revoke this consent by notifying the court and the adoption agency in writing that I wish to
revoke this consent. I understand that my written notice to revoke must be delivered to the court
within 21 days after this consent is signed or on or before this date: _______________________
21 days from date consent is signed
b) If the adoption agency and I agree, we may jointly revoke this consent any time before finalization of
the adoption. However, if the adoption agency does not agree to revoke after the 21 day period, then
this consent will become irrevocable on the 22
nd
day after it was signed; and
c) If this consent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days after
the minor is placed for adoption, without good cause, then I may petition the court to have this
consent revoked. The petition may be filed in either the court in which the adoption is pending or in
the court where the consent is signed.
3. I certify that the following statements are true: (check each box if the statement is true. If the statement is not true, leave
the box empty.)
☐ I have read this consent or I have had it read to me;
☐ I am signing this consent voluntarily;
☐ Before signing this consent, I was informed of the meaning and consequences of adoption. I
understand that, unless otherwise provided in this consent, my signing of this consent and failure to
timely revoke the consent, terminates any right I may have to object to the minor’s adoption by the
prospective adoptive parent(s).
☐ I have been informed about the consequences of misidentifying the other parent of this child;
☐ I have been informed about the procedure for releasing information about health, characteristics, and
identity of myself to the adoptee;
☐ 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.)
☐ 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.)
☐ I have provided to the adoptive parent(s), or their agent, 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 that it is in the best interests of the minor child that I keep the court or the
adoption agency informed of my current address and any family health problems of mine which may
develop and which could affect the child. This will allow the court or agency to respond to any
inquiries concerning the minor’s medical or social history.
☐ 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
and the legal procedure for release of the parent’s identity.
700-00128 – Relinquishment of Minor to Agency for Adoption (07/2016) Page 3 of 4
☐ 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.
☐ I have been a recipient of public assistance during the last 12 months: ☐ yes ☐ no
☐ The minor child is an Indian child as defined by the federal Indian Child Welfare Act: ☐ yes ☐ no
With respect to notice of further proceedings related to this adoption (check one):
☐ 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.
☐ I understand that the adoption will make any orders or agreement for visitation or communication with
the minor, unenforceable.
☐ I understand that after this consent has been executed in compliance with the law and not revoked, the
consent becomes final and may not be revoked or set aside for any reason, including the failure of the
adoptive parent(s) or agency to permit me to visit or communicate with the minor. I further understand
that this consent will extinguish all parental rights and obligations, and the adoption will completely
terminate every aspect of my legal relationship with the minor, except for arrearages of child support.
☐ Before executing this Consent, I was informed of the availability of personal counseling by a certified
adoption counselor or other counselor of my choice.
4. Conditions:
I am signing this consent under the following conditions permitted by law [15A V.S.A. § 2-406(e)]:
☐ No conditions
☐ The following condition(s) authorized under 15A V.S.A. § 2-406(e):
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. I have participated as a party, witness or in some other capacity in litigation concerning the custody or
support of the minor: ☐ yes ☐ no
(If yes, please describe the litigation and your role on a separate sheet of paper and attach it to this consent.)
6. I have knowledge about a person or agency who has physical or legal custody of the minor, or who
claims to have custody or visitation rights. ☐ yes ☐ no
(If yes, please describe what you know about these legal proceedings or claims on a separate sheet of paper and
attach it to your consent.)
I swear or affirm that the facts set forth in this consent are true and correct to the best of my knowledge and
belief.
On:
Date
At:
Signature of Parent
City, County and State
Printed Name
700-00128 – Relinquishment of Minor to Agency for Adoption (07/2016) Page 4 of 4
To be filled in by the court
CERTIFICATION
The Consent to Adoption set forth above was signed in my presence pursuant to 15A V.S.A. §2-405. The
facts set forth in the consent were sworn to under oath or affirmation. I hereby certify that I explained to
the person signing the consent the contents and consequences of the consent, and, to the best of my
knowledge, the person executing the consent:
a. Read this Consent or had it read to him/her;
b. Signed this consent voluntarily;
c. Received a copy of this Consent;
d. Was informed about the consequences of misidentifying the other parent of the minor;
e. Was informed about the procedure for releasing information about the his or her health,
characteristics and identity to the adoptee;
f. Was advised by an attorney who is not representing the adoptive parent(s) or the adoption agency to
which the child is being relinquished if the person signing the consent is a minor. The name of the
attorney who gave him or her advice is _________________________ and this attorney was present
when this consent is being executed;
g. Was informed of his or her right to have an attorney represent him or her in this matter, specifically
an attorney who is not representing the adoptive parent or the adoption agency to which the child is
being relinquished, if the person signing the consent is an adult;
h. Has responded to inquiries as provided for under 15A V.S.A. §3-404, if the person signing this consent
is a mother who has not identified a biological father;
i. Has provided the names and addresses of the persons described in 15A V.S.A. §3-401(a)(6), if a
parent is deceased;
j. Understands that personal counseling was available by a certified adoption counselor or other
counselor of his or her choice;
k. Has been made aware 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
and the statutory procedure for release of a parent’s identity under Article 6 of the Vermont
Adoption Act.
☐ The Court has received an Acceptance of Relinquishment from the above named agency or a Statement
of Intent to Adopt.
Date
Signature
Printed Name of Probate Judge or Other Person Authorized by the Probate Judge
I acknowledge that I have received a copy of this document signed by myself and the probate judge or other
person authorized by the probate judge.
Date
Signature of Parent
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Form 700 00128 (Vermont Judiciary)

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Completed 15 July 2020

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