Fillable Petition To Adopt Adult (Vermont Judiciary)

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Petition To Adopt Adult (Vermont Judiciary)

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700-00131A – Petition to Adopt Adult (11/2018) Page 1 of 4
STATE
OF
VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of:
PETITION TO
ADOPT AN ADULT
15A V.S A. §5-105
I/We, the undersigned petitioner(s), state as follows:
Part I - General Information
Information About the Person to be Adopted:
Full Name _____________________________________________________________________
Date of Birth: ____________________________ Place of Birth: ____________________________
Complete Mailing Address: ________________________________________________________________
Marital Status: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, state the date and place of marriage: ______________________________________________
Name by which Adult will be known after adoption: ______________________________________________
Request for New Birth Certificate:
☐ 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:
Prospective Adoptive Parent A Information:
Full Name Prospective Adoptive Parent A: _______________________________________________________
Date of Birth: _____________________________ Place of Birth: _____________________________
Maiden Name: _______________________________________________________________________
Complete Mailing Address: _________________________________________________________________
Town & State of Residence: ______________________________________________________________
Length of Residence at Current Address: ______________ Phone Number: ____________________________
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, state the date and place of marriage: ______________________________________________
700-00131A – Petition to Adopt Adult (11/2018) Page 2 of 4
Prospective Adoptive Parent B Information:
Full Name Prospective Adoptive Parent B: _______________________________________________________
Date of Birth: _____________________________ Place of Birth: _____________________________
Maiden Name: _______________________________________________________________________
Complete Mailing Address: _________________________________________________________________
Town & State of Residence: ______________________________________________________________
Length of Residence at Current Address: ______________ Phone Number: ____________________________
I am: ☐ Single/Never Married ☐ Married
☐ In a Civil Union ☐ Single/Divorced
☐ Spouse/Partner Deceased
If married, state the date and place of marriage: _____________________________________________
State the Duration and Nature of the relationship between the Adoptee and Adoptive Parents:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Part II - Certifications by Petitioners
The prospective adoptive parent(s) and the adoptee certify as follows:
1. The prospective adoptive parent(s) and the adoptee desire to assume the legal relationship of parent
and child and to have all of the rights and be subject to all of the duties of that relationship.
2. The adoptee understands that a consequence of the adoption will be to terminate the adoptee's
relationship as the child of an existing parent, but if the adoptive parent is the adoptee's stepparent, the
adoption will not affect the adoptee's relationship with a parent who is the stepparent's spouse, but will
terminate the adoptee's relationship to the adoptee's other parent, except for the right to inherit
from or through that parent.
3. The adoptee and the prospective parent(s) understand the consequences the adoption may have for
any right of inheritance, property, or support from adoptive and biological parents.
Part III - Persons Interested in Adoption Proceeding
Full Name and last known address of any other person whose consent to this adoption is required:
Full Name: _____________________________________________________________
Complete Mailing Address: _____________________________________________________________
Town & State of Residence: _____________________________________________________________
Full Name: _____________________________________________________________
Complete Mailing Address: _____________________________________________________________
Town & State of Residence: _____________________________________________________________
Full Name: _____________________________________________________________
Complete Mailing Address: ______________________________________________________________
Town & State of Residence: _____________________________________________________________
700-00131A – Petition to Adopt Adult (11/2018) Page 3 of 4
Full Name, age and last known address of each biological or adopted child of the prospective adoptive parents.
If adopted, state the date and place of adoption
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Adoption Information, if any: ____________________________________________________________
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Adoption Information, if any: ____________________________________________________________
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Adoption Information, if any: ____________________________________________________________
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Adoption Information, if any: ____________________________________________________________
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Adoption Information, if any: ____________________________________________________________
Name. age and last known address of each living parent or child of the adoptee
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Full Name: __________________________________________ Age: ________
Complete Mailing Address: ____________________________________________________________
Part IV - Documents Attached to the Petition
The following documents must be attached to the petition:
█ Certified copy of Adoptee’s birth certificate
█ Certified copy of birth certificate for each adoptive parent
█ Any required consent that has been executed
1
█ Filing Fee
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, Adoptive Parent A
City, County and State
Printed Name
1
The only required consent to the adoption of an adult or emancipated minor is the consent of the spouse or civil union partner of
the prospective adoptive parent. (Form # PA139e)
700-00131A – Petition to Adopt Adult (11/2018) Page 4 of 4
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 Adoptee
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, Adoptive Parent B
City, County and State
Printed Name
Signed and sworn to before me:
Date Signature of Notary Public Expiration Date
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Petition To Adopt Adult (Vermont Judiciary)

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Completed 15 July 2020

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