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FORM 139G. CONSENT TO ADOPTION

STATE OF VERMONT PROBATE COURT

DISTRICT OF ______________, SS. Docket No. _____________

IN RE THE ADOPTION OF ___________________________________________, A MINOR

of ____________________________

CONSENT TO ADOPTION

15A V.S.A. § 2-406

NOW COMES the undersigned person, ______________, and does swear or affirm

under oath to the facts set forth herein and does consent to the adoption described herein as set

forth in more detail below:

(1) My full name is __________________________________; my date of birth is ________

__________________; my current mailing address is ________________________________

______________________; I am (check one) [ ] married [ ] single and never married; [ ] single

and divorced.

(2) The full name of the minor to be adopted is ______________________________________:

(circle one) his or her date of birth is ______________________________ and the time of birth

was ____________ (A.M./P.M.). The minor is currently living at the following address:

______________________________________________________________________________

______________, and has lived there for ____________ (weeks, months or year).

(3a) The name and address of the adoptive parents are known to me and their name(s) and

address is as follows (Please give the names, addresses and telephone numbers, if available, or if

unavailable or unknown to you, please give whatever information you have):

_____________________________________________________________________________

The name of the attorney representing the prospective adoptive parent(s) is: ________________

________________________________ and his or her address and telephone number is:

____________________________________________________________________________

(3b) The full name and address of the other parent is:

_____________________________________________________________________________

The date of birth of the other parent is _______________________________; the other parent is

(check one) [ ] married; [ ] single and never married; [ ] single and divorced.

If the full name and address is not provided, please state the reason:

_____________________________________________________________________________

(4) I am voluntarily and unequivocally consenting to the transfer of legal and physical

custody to, and adoption of, the above-named minor child by the proposed adoptive

parent(s) who I have selected and who are identified in paragraph #3 above. I further

believe that the adoption of the minor is in the minor's best interest.

(5) I understand that I may revoke this consent by notifying the court in writing within 21 days

after this consent is executed that I wish to revoke this consent. (I understand that if I and the

prospective parents agree, we may jointly revoke this consent anytime before finalization of the

adoption. If the prospective adoptive parents do not agree to revoke after the 21 day period then

the consent becomes irrevocable on the 22nd day after its execution.) I understand that if this

consent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days after

the minor was placed for adoption without good cause, then I may petition the court to have this

consent revoked. The petition may be filed in the court in which the adoption is pending, if

known, or in the court in which this consent is signed.

(6) The name and address of the court in which the adoption petition has been filed, or will be

filed, is: _____________________________________________________________________.

If unknown, the name and address of the court in which a motion to set aside this consent on the

basis of fraud, duress or otherwise, would be filed in: __________________________________

________________________________ District Probate Court located at __________________

________________________________________.

(7) I certify to the following:

(a) I have read this consent, or I have had it read to me;

(b) English is my native language (if not, see 15A V.S.A. § 2-406(a));

(d) I have received a copy of this consent;

(e) Before signing this consent, I have been 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 revoke the consent terminates any right I may have to object to the minor's

adoption by the prospective adoptive parent(s). I also have been informed about the

consequences of misidentifying the other parent of this child and the procedure for releasing

information about health, characteristics, and identity of myself to the adoptee;

(f) If I am a minor, I certify that I was advised by an attorney who is not representing the

adoptive parent or the adoption agency to which the child is being relinquished; the name of the

attorney is __________________________ and he or she is present as this consent is being

executed;

(g) If I am an adult, I certify that I was informed of my right to have an attorney represent me in

this matter who is not representing the adoptive parent or representing the adoption agency to

which the child is being relinquished;

(h) I have provided to the adoptive parents, or their agent, nonidentifying information and

information about the child's and my family's health history and background as required by 15A

V.S.A. § 2-105, and I understand that before the adoption becomes final, if information becomes

available to me which was unavailable previously, then I have an obligation to provide this

information;

(i) I have been made aware that it is in the best interests of the adoptee that I keep the court or

the adoption agency informed of my current address and any family health problems of mine

which may develop which could affect the child so that the court or agency may respond to any

inquiry concerning the adoptee's medical or social history. I have also 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 adoptee and the procedure for release

of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

(j) 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 under 15A V.S.A. § 7-103 and

which are itemized on an attachment to this consent; I (circle one) have/have not been a recipient

of public assistance during the last 12 months;

(k) The minor child (circle one) is/is not an Indian Child as defined in the Indian Child Welfare

Act, 25 U.S.C. § 1901 et seq.

(l ) That I (choose one)

[ ] waive notice of any proceeding for adoption of the adoptee;

[ ] waive notice of the adoption unless the adoption is contested, appealed or denied;

[ ] do not waive notice of any proceeding for adoption and I would like to be notified at my

address as set forth above;

(m) I understand that the adoption will make any orders or agreements for visitation or

communication with the minor unenforceable;

(n) I understand that after this consent has been executed in compliance with § 2-405 and not

revoked in compliance with § 2-408 or § 2-409, then the consent becomes final and may not be

revoked or set aside for any reason, including the failure of the adoptive parent or agency to

permit me to visit or communicate with the minor adoptee. I further understand that this consent

will extinguish all parental rights and obligations, and the adoption will completely terminate

every aspect of the legal relationship which I may have concerning the minor, except for

arrearages of child support.

(o) That before executing this consent I was informed of the availability of personal counseling

by a certified adoption counselor, or other counselor of my choice and legal counseling.

(8) If this consent is being made conditional upon other conditions which are authorized under

15A V.S.A. § 2-406(e), that those conditions are set forth with particularity here. (If none, so

state.)

_____________________________________________________________________________

(9) I (circle one) have/have not participated as a party, witness, or in any other capacity in any

litigation or action concerning the custody or support of the above-named minor in Vermont or

any other state. I (circle one) have/have no knowledge of any person or adoption agency or state

agency who has physical or legal custody of the child, or who claims to have custody or

visitation rights with this child. (Any affirmative answer in this paragraph requires a description

of the action or claim, including the court and docket number if available.)

I swear that the factual information set forth in this consent is true and correct to the best of my

knowledge and belief.

Dated this ____ day of ______, _____, at ________________, County of ________________,

and State of __________________.

_____________________________________________

(signature)

______________________________________________

(typed or printed name)

CERTIFICATION

The Consent to Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. §

2-405. Those facts set forth in the consent were sworn to, under oath or affirmation, and I hereby

certify that I explained to the person executing the consent the contents and consequences of the

consent, and to the best of my knowledge or belief, the person executing the consent:

(a) read this consent, or had it read to them;

(b) signed this consent voluntarily;

(d) was informed about the consequences of misidentifying the other parent of this child and the

procedure for releasing information about health, characteristics, and identity of myself to the

adoptee;

(e) if a minor, the minor signing the consent was advised by an attorney who is not representing

the adoptive parent or the adoption agency to which the child is being relinquished; the name of

the attorney is ____________________________ and he was present as this consent was

executed;

(f) if an adult, the person was informed of his or her right to have an attorney represent them in

this matter who is not representing the adoptive parent or representing the adoption agency to

which the child is being relinquished;

(g) if a mother who has not identified a biological father, then the mother responded to inquiries

as provided for under 15A V.S.A. § 3-404;

(h) if a parent is deceased, then the person signing the consent has provided the names and

addresses of the persons described in 15A V.S.A. § 3-401(a)(6);

(i) the person understands that personal counseling was available by a certified adoption

counselor, or other counselor, of his or her choice;

(j) I have received a statement from the adoptive parent indicating an intention to adopt as

required in 15A V.S.A. § 2-405(e).

(k) The person signing this consent has also 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 wellbeing of the adoptee and the procedure for release of the parent's identity

pursuant to Article 6 of the Vermont Adoption Act.

Dated this ____ day of ______, _____, at _____________, County of ___________________,

and State of _____________________________________.

_______________________________________________

(signature)

________________________________________________

(printed name) of Judge or other person authorized under statute

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