Fillable Form 700 00131 1 (Vermont Judiciary)

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Form 700 00131 1 (Vermont Judiciary)

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700-00131 – Petition to Adopt Minor (08/2019) Page 1 of 5
STATE
OF
VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
PETITION TO
ADOPT MINOR CHILD
I/We ask the Court to permit me/us to adopt the minor child named above. I/We swear or affirm under oath
that the facts set forth below are true to the best of my/our knowledge and belief:
Part I - General Information
Information About the Minor Child to be Adopted:
Full Birth or Current Legal Name: ___________________________________________________________
Date of Birth: _____________________________ Time of Birth: ____________________________
Name by which child will be known after adoption: ______________________________________________
Town & State where child was born: _________________________________________________________
Gender of Minor ☐ Male ☐ Female
Describe any assets or property owned by the child and the value of each asset.
Assets/Property Value
__________________________________________________ $____________________________
__________________________________________________ $____________________________
__________________________________________________ $____________________________
Request for New Birth Certificate:
☐ No Request was made by Petitioners
☐ Petitioners have requested that a new birth certificate be issued by the Supervisor of Vital Records that
includes the name, date of birth, and place of birth of the adoptive parent(s) as set forth below.
Petitioner A Information:
Full Name Petitioner A: _____________________________________________________________________
Date of Birth: _____________________________ Place of Birth: ____________________________
Last Name at Birth: _______________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town & State of Residence: ______________________________________________________________
Length of Residence at Current Address: ______________ Phone Number: ___________________________
Describe Your Relationship to the Child: ________________________________________________________
Occupation: ___________________________________ Annual Income: $__________________________
I have the resources and the facilities to provide care and support for this child. ☐ Yes ☐ No
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, has spouse been judicially determined to be incompetent? ☐ Yes ☐ No
Date of most recent pre-placement evaluation: _________________________________________________
700-00131 – Petition to Adopt Minor (08/2019) Page 2 of 5
Petitioner B Information:
Full Name Petitioner B: _____________________________________________________________________
Date of Birth: _____________________________ Place of Birth: ____________________________
Last Name at Birth: _______________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town & State of Residence: ______________________________________________________________
Length of Residence at Current Address: ______________ Phone Number: ___________________________
Describe Your Relationship to the Child: ________________________________________________________
Occupation: ___________________________________ Annual Income: $__________________________
I have the resources and the facilities to provide care and support for this child. ☐ Yes ☐ No
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, has spouse been judicially determined to be incompetent? ☐ Yes ☐ No
Date of most recent pre-placement evaluation: _________________________________________________
I state that to the best of my knowledge and belief, the minor ☐ is ☐ is not Native American or of Native
American heritage. (check appropriate box)
I state to the best of my knowledge and belief, any law governing interstate or inter-country placement which
applies to this adoption has been complied with.
Biological Parent A Information: provide all information that you know about
Full Name Biological Parent A: _____________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Phone Number: ___________________________
Biological Parent B Information: provide all information that you know about
Full Name Biological Parent B: _____________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Phone Number: ___________________________
☐ I do not know some or all of the information about the other parent because:
_____________________________________________________________________________________
Were the parents married at the time of the child’s birth?
☐ Yes ☐ No ☐ Don’t Know
If no, were either or both of the parents married to someone else?
☐ Yes ☐ No ☐ Don’t Know
Are the parents divorced?
☐ Yes ☐ No ☐ Don’t Know
If yes, how was custody (parental rights) awarded? ☐ To Parent A ☐ To Parent B
☐ Jointly to Both ☐ Don’t Know
Consent, Relinquishment or Disclaimer of Parental Interest:
The following person(s) has/have signed a consent, relinquishment or disclaimer of parental interest:
Name Relationship to Child Type of Document Signed
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
700-00131 – Petition to Adopt Minor (08/2019) Page 3 of 5
The following person(s) has a parental relationship that has not been terminated and a consent or
relinquishment may be required:
Name Relationship to Child Facts that may explain
Lack of Consent
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
Prior Adoption Petitions
I have previously filed an adoption petition in another court:
☐ Yes ☐ No
If yes, describe what happened to your petition:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Prior or Pending Court Proceedings Involving this Child
Describe any Court proceedings or Court Orders related to this child concerning child support, custody
(parental rights and responsibilities) or visitation (parent child contact). Use additional sheets if necessary
Name of Court Docket Number Type of Court Proceeding
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
__________________________ ______________________ _________________________
Current Residence of Minor Child
☐ The child has resided with the petitioner(s) since ______________________________.
☐ The child was placed with petitioner by an agency. The name and address of the agency is:
__________________________________________________________________________________
☐ The child was placed with petitioner by __________________________. The relationship between
the child and this person is: __________________________________________________________.
☐ The child is not currently residing with the petitioner(s) because:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Legal Custody of Minor
I/We have legal custody of the minor:
☐ Yes ☐ No
If yes, describe the circumstances under which you obtained custody of the minor:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Home Study
☐ A home study is being prepared by: ________________________________________________________
Name and Address of Preparer
☐ I intend to request a waiver of the home study
☐ Yes ☐ No
If you are requesting a waiver, you must attach a letter to the court explaining why a waiver would be
appropriate
700-00131 – Petition to Adopt Minor (08/2019) Page 4 of 5
Part II - Persons Interested in Adoption Proceeding
Mother of Child:
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Husband of Mother: (if the child was born during the marriage or within 300 days after its termination)
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Name of Biological Father Identified by Mother:
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Any Other Man who was not married to the mother at the time of the child’s birth, but has acknowledged paternity
and has demonstrated a parental relation to the child and financial responsibility for the child:
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Name of the Child’s Legal Guardian:
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Name of the Agency or Person who placed child with petitioners:
Full Name _____________________________________________________________________
Mailing Address (town, state, zip): ______________________________________________________________
Town of Residence: _____________________________________________________________________
Part III - Documents Attached to the Petition
Petitioner(s) must make reasonable efforts to obtain the following documents and file them with the petition:
A. Originals or Certified Copies of:
█ Child's birth certificate or other record of date and place of birth;
█ Any consent, relinquishment, order terminating parental rights or disclaimer of parental interest that
have been executed;
█ Written certification required of person before whom the consent or relinquishment was executed;
█ Each parent or former parent's marriage certificate, decree of divorce, annulment or dissolution, or
agreement of legal separation;
█ Any court order determining the former parent's incompetence;
█ Any existing court order or petition in a pending proceeding concerning custody of, or visitation or
communication with, the child;
█ Petitioner's marriage certificate, decree of divorce, annulment or agreement of legal separation;
█ Any court order determining that the spouse of the petitioner is incompetent.
B. Copies of:
█ Birth certificates of petitioner(s);
█ Pre-placement evaluation on the petitioner(s);
700-00131 – Petition to Adopt Minor (08/2019) Page 5 of 5
█ Post-placement evaluation;
█ Report on the child and family's background information required by § 2-105;
█ Any agreement with a public agency for adoption subsidy;
█ Any collateral agreement between the petitioner and parent or guardian or any agency;
█ Any request for nondisclosure signed by the parent or former parent.
C. If an agency placed the child for adoption, a verified statement from the agency is required. [See 15A
V.S.A. § 3-305(a)(10)]
Part IV - Unavailable Information
I am unable to provide the following information in Parts I, II or III of this petition because the information is
not known to me or not available to me after a reasonable attempt to get it.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and
belief.
On:
Date
At:
Signature of Petitioner A
City, County and State
Printed Name
I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and
belief.
On:
Date
At:
Signature of Petitioner B
City, County and State
Printed Name
Signed and sworn to before me:
Date Signature of Notary Public Expiration Date
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Form 700 00131 1 (Vermont Judiciary)

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Completed 15 July 2020

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