Consent of Custodial Biological Parent to Adoption (Stepparent or Partner Adoption)

This form is to be used in drafting the Stepparent’s Spouse Consent to the Adoption.Download

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700	-00139 	– Consent of Custodial Biological Parent 	to Adoption	 (Stepparent	/Partner	 Adoption 	(04/201	7) 	Page 	1 of 2 	
STATE	 OF	 VERMONT	 	 	
SUPERIOR COURT	 	 	PROBATE	 DIVISION	 	
 	Unit	 	 	Docket No. 	 	
 	 	
In re Adoption of:	 	 	
 	
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 	M	inor to be 	Adopted:	 	
 	Minor’s 	Name: ___________________	___________________	 Date of Birth: _____________________________	 	
 
Information about the 	Attorney Who R	epresents the 	Prospective 	Adoptive 	Parents:	 	
 	Name of Attorney: __________________________________	 Phone: __________________________________	 	
 	Address	: ____	_____	_________________________________	 City/State/Zip: ____________________________	 	
 	
 
 
Agreements	: 	
I understand and agree that: 	(Check All That A	pply	) 	
 	☐	 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 co	mmunication 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 	
throu	gh the	 parent	 of the	 minor	 who	 is no	t living with th	e 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 g	rounds for revoking consent or setting aside the 	
adoptio	n; and

700	-00139 	– Consent of Custodial Biological Parent 	to Adoption	 (Stepparent	/Partner	 Adoption 	(04/201	7) 	Page 	2 of 2 	
 
 	 	C. The paren	t who is no	t living with th	e stepparen	t re	mains liabl	e fo	r arreara	ges of child 	support	 	
unless	 r e l e a s e d   f r o m  	that	 obli	gation	 by	 the	 parent	 who	 lives	 with	 the	 c h i l d  	and	 by	 any	 	
govern	mental	 agency	 pro	viding	 f i n a n c i a l  	assistance	 to the	 minor.	 	
 
This consent is not, and cannot be, a waiver of any further notice to me of the proceeding for adoption of the 
minor by the person seeking to adopt.	 	
 
 
Voluntary Consent:	 	
 	I state that I have 	legal and physical custody of this minor.   I voluntarily and unequivocally consent to 	
the adoption of this minor child.	 	
 
 
I swear or affirm that the facts set forth in this consent are true and correct to the best of my knowledge and 
belief.	 	
 
 
 
 	 	 	
Date	   	
At:  	 	
 	Signature	 	   	
City, County and State 	 	 	Printed Name	 	
 
 
 
 
Signed and confirmed in the presence of the Judge or in the presence of a person directed by the Judge	 	
 
 	 	 
 	
Date	 	 	Signature 	 	
 	
 
 	
Printed Name of Judge or Other Person Authorized by Judge