Vt. R. Prob. P. Form 125A Vermont Rules of Probate Procedure, Form 125A

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 125A. 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 years).

(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:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 If 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 is:  _______________ 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));

 (c) I am signing this consent voluntarily;

 (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 (chose 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), then 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;

 (c) received a copy of this consent;

 (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 well-being 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 _______________, 19_____, at _______________, County of ____________________, and State of ____________________.

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

 [Former Form 125A deleted and Temporary Form 125A adopted, effective July 1, 1996.  Amended and redesignated effective March 1, 1997; amended July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 125B Vermont Rules of Probate Procedure, Form 125B

Form 125B. Relinquishment of Minor to Agency for Adoption

STATE OF VERMONT PROBATE COURT DISTRICT OF _______________.SS  DOCKET NO. _______

IN RE THE ADOPTION OF ____________________, A MINOR OF ____________________


RELINQUISHMENT OF MINOR TO AGENCY FOR 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 relinquish a child for adoption 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.

(2a) The full recorded name of the minor being relinquished for adoption 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 years).  My relationship to the minor being relinquished is:  _______________ (parent, legal guardian, etc.) and I have authority to relinquish this minor for adoption.

(2b) The full name and address of the other parent is:  ________________________ _______________________________________________________________________________ ______________________________________________________________________________

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

(3) The name, address and telephone number of the adoption agency to which the relinquishment is being made is:

Name:  ________________________________________________________________________

Address:  ______________________________________________________________________ ______________________________________________________________________________

Telephone No. __________________________________________________________________ .  ___________________________________________________________________________.

(4) After careful consideration, I believe that it is in the best interests of my said child to be placed for adoption.  I am voluntarily and unequivocally consenting to the permanent transfer of legal and physical custody of the above minor to the above adoption agency for the purposes of adoption and to take any and all other measures that may be in the best interests of the minor.

(5) I understand that I may revoke this relinquishment by notifying the court in which this relinquishment was signed, and the above adoption agency, in writing within 21 days after this relinquishment is executed that I wish to revoke this relinquishment.  (I understand that if I and the above adoption agency agree, we may jointly revoke this relinquishment anytime before finalization of the adoption.  If the adoption agency does not agree to revoke after the 21 day period has expired, then the relinquishment becomes irrevocable on the 22nd day after its execution.)  I understand that if this relinquishment is obtained by fraud or duress, or if a condition which would permit revocation had occurred, then I may petition the court to have this relinquishment revoked.  A motion to set aside this relinquishment on the basis of fraud, duress, or otherwise, would be filed in the ______________________________ District Probate Court located at ______________________________.

(6) I certify to the following:

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

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

 (c) I am signing this relinquishment voluntarily;

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

 (e) Before signing this relinquishment, I have been informed of the meaning and consequences of adoption.  I understand that, unless otherwise provided in this relinquishment, my signing of this relinquishment and failure to revoke the relinquishment terminates any right I may have to object to the minor's adoption by the adoptive parent(s) as authorized by the agency.  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.  I have provided accurate information about the identity of the minor's other parent.  I understand that when the child reaches the age of majority, he or she will be given information about my identity upon request unless I have signed a request for nondisclosure of identifying information.  If I have signed such a request, I understand that I may withdraw it at any time;

 (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 relinquishment 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 agency 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.  I have also been made aware of 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 relinquishment except for payments which are authorized under 15A V.S.A. § 7-103 and which are itemized on an attachment to this relinquishment;  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 relinquishment has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2- 409, then the relinquishment 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 relinquishment 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 relinquishment I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling.

(7) If this relinquishment is being made conditional upon other conditions which are authorized under 15A V.S.A. § 2-406(e), then those conditions are set forth with particularity here.  (If none, so state.)

________________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________

(8) 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 information concerning any prior custody proceedings (including adoption, guardianship, divorce or paternity actions) concerning the minor which are pending or have been completed.  I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of 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 relinquishment 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 Relinquishment of Minor For Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. § 2-405.  Those facts set forth in the relinquishment were sworn to, under oath or affirmation, and I hereby certify that I explained to the person executing the relinquishment the contents and consequences of the relinquishment, and to the best of my knowledge or belief, the person executing the relinquishment:

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

 (b) signed this relinquishment voluntarily;

 (c) received a copy of this relinquishment;

 (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 relinquishment 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 relinquishment 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 relinquishment 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 adoption agency indicating an acceptance of the relinquishment as required in 15A V.S.A. § 2-405(f).

 (k) The person signing this relinquishment 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 well-being 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

 [Former Form 125B deleted and Temporary Form 125B adopted effective July 1, 1996.  Amended and redesignated effective March 1, 1997; amended July 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 128 Vermont Rules of Probate Procedure, Form 128

 

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 128. Relinquishment of Minor to Agency for Adoption

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________, SS  Docket No. __________

IN RE THE ADOPTION OF __________, A MINOR OF ________________

________________________________________

RELINQUISHMENT OF MINOR TO AGENCY FOR 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 relinquish a child for adoption 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.

(2a) The full recorded name of the minor being relinquished for adoption 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 years).  My relationship to the minor being relinquished is:  __________ (parent, legal guardian, etc.) and I have authority to relinquish this minor for adoption.

(2b) 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:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

(3) The name, address and telephone number of the adoption agency to which the relinquishment is being made is:

Name:  ________________________________________________________________________

Address:  _____________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________.

Telephone No. ____________________.

(4) After careful consideration, I believe that it is the best interests of my said child to be placed for adoption.  I am voluntarily and unequivocally consenting to the permanent transfer of legal and physical custody of the above minor to the above adoption agency for the purposes of adoption and to take any and all other measures that may be in the best interests of the minor.

(5) I understand that I may revoke this relinquishment by notifying the court in which this relinquishment was signed, and the above adoption agency, in writing within 21 days after this relinquishment is executed that I wish to revoke this relinquishment.  (I understand that if I and the above adoption agency agree, we may jointly revoke this relinquishment anytime before finalization of the adoption.  If the adoption agency does not agree to revoke after the 21 day period has expired, then the relinquishment becomes irrevocable on the 22nd day after its execution.) I understand that if this relinquishment is obtained by fraud or duress, or if a condition which would permit revocation had occurred, then I may petition the court to have this relinquishment revoked.  A motion to set aside this relinquishment on the basis of fraud, duress, or otherwise, would be filed in the __________ District Probate Court located at __________.

(6) I certify to the following:

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

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

 (c) I am signing this relinquishment voluntarily;

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

 (e) Before signing this relinquishment, I have been informed of the meaning and consequences of adoption.  I understand that, unless otherwise provided in this relinquishment, my signing of this relinquishment and failure to revoke the relinquishment terminates any right I may have to object to the minor's adoption by the adoptive parent(s) as authorized by the agency.  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.  I have provided accurate information about the identity of the minor's other parent.  I understand that when the child reaches the age of majority, he or she will be given information about my identity upon request unless I have signed a request for non-disclosure of identifying information.  If I have signed such a request, I understand that I may withdraw it at any time;

 (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 relinquishment 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 agency 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 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 interest 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.  I have been made aware of 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 relinquishment except for payments which are authorized under 15A V.S.A. § 7-103 and which are itemized on an attachment to this relinquishment;  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 relinquishment has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2-409, then the relinquishment 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 relinquishment 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 relinquishment I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling.

(7) If this relinquishment is being made conditional upon other conditions which are authorized under 15A V.S.A. § 2-406(e), then those conditions are set forth with particularity here.  (If none, so state.)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

(8) 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 information concerning any prior custody proceeding (including adoption, guardianship, divorce or paternity actions) concerning the minor which are pending or have been completed.  I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of 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 relinquishment 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 Relinquishment of Minor For Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. § 2-405.  Those facts set forth in the relinquishment were sworn to, under oath or affirmation, and I hereby certify that I explained to the person executing the relinquishment the contents and consequences of the relinquishment, and to the best of my knowledge or belief, the person executing the relinquishment:

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

 (b) signed this relinquishment voluntarily;

 (c) received a copy of this relinquishment;

 (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 relinquishment 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 relinquishment 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 relinquishment 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 adoption agency indicating an acceptance of the relinquishment as required in 15A V.S.A. § 2-405(f).

 (k) The person signing this relinquishment 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 well-being 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

 


Vt. R. Prob. P. Form 131 Vermont Rules of Probate Procedure, Form 131

Form 131. Adoption Petition

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________, SS  DOCKET NO. __________

IN RE THE ADOPTION OF ____________, OF ______________________

ADOPTION PETITION


15A V.S.A. § 3-404


Part I.

 The undersigned petitioner(s) represent that:

1. The person to be adopted is:  Name: ____________________, Place of birth: _____________________________  Date of birth: __________, Time of birth: __________  Sex: __________, To be known as: ________________________________________  Child has resided with petitioner(s) since: __________  Child [ ] is [ ] is not an Indian child as defined by Indian Child  Welfare Act.

2. The petitioner(s) are:

 

Name: ____________________, Maiden name: ________________________________  Date of birth: __________,

Place of birth: ______________________________  

Mailing address:  _________________________________________________________________________  _________________________________________________________________________  

Town and state of residence: ____________________________________________  

For how long? ___________________________________________________________

 Occupation: ____________________, Approximate income: ___________________

Current marital status: __________, Is divorce pending? _________________  

If married, has spouse been judicially determined to be incompetent?  _________________________________________________________________________  

Relationship to adoptee: ________________________________________________  

Date of most recent favorable preplacement evaluation: __________________  

Date, court and disposition of any previous petition to adopt: __________  _________________________________________________________________________  _________________________________________________________________________  

Name: ____________________, Maiden name: ________________________________  

Date of birth: __________, Place of birth: ______________________________  

Mailing address:  _________________________________________________________________________  _________________________________________________________________________  

Town and state of residence: ____________________________________________  

For how long? ___________________________________________________________  

Occupation: ____________________, Approximate income: ___________________  

Current marital status: __________, Is divorce pending? _________________

3. The petitioners acquired physical custody of the minor on: ______________ If the child is not in the physical custody of the petitioners, explain  the reason and the date and manner in which the petitioners intend to  obtain physical custody:  _________________________________________________________________________  _________________________________________________________________________

4. If the child was born out of wedlock, have the parents intermarried?

 [ ] Yes [ ] No  If the child's parents are divorced, custody was awarded to _____________

5. The name and address of the person or agency who placed the child with  the petitioners is: ___________________________________________________  _________________________________________________________________________  _________________________________________________________________________  If not an agency, the relationship of the person who placed the child  with the petitioners is: ______________________________________________

6. The description and approximate value of known property of the minor is:

 _________________________________________________________________________  _________________________________________________________________________

7. The petitioner is aware that the following court orders are in effect or

 pending regarding the child:  Child support: __________________________________________________________  Custody: ________________________________________________________________  Visitation or contact: __________________________________________________

8. The petitioner(s) have completed the list of interested persons in Part I and have attached or explained in an attached affidavit the absence of  the documents listed in Part III.

9. Any law governing interstate or intercountry adoption was complied with, if applicable.

10. The petitioners have the facilities and resources to provide for the care

 and support of the child and request that they be permitted to adopt  the child. In addition, the following relief is sought: _______________  _________________________________________________________________________  _________________________________________________________________________

Part II. Persons Interested in Adoption Proceeding

The undersigned petitioner(s) represents that the following is a list of persons interested in the adoption of the above-named child as far as is known to me:

1.  Mother's name: __________________________________________________________  Mailing address: ________________________________________________________  _________________________________________________________  Town of residence: ______________________________________________________

2.  Name of husband of the mother, if the child was born during the marriage

 or within 300 days after its termination: _____________________________  Mailing address: ________________________________________________________  Town of residence: ______________________________________________________

3.  Name of biological father identified by the mother: _____________________

 Mailing address: ________________________________________________________  _________________________________________________________________________  Town of residence: ______________________________________________________

4.  Name of any other man who was not married to the mother at the time of

 the child's birth, has acknowledged paternity and has demonstrated a  parenting relationship with the child, including financial: ___________  Mailing address: ________________________________________________________  _________________________________________________________________________  Town of residence: ______________________________________________________

5.  Name of the child's legal guardian: _____________________________________

 Mailing address: ________________________________________________________  _________________________________________________________________________  Town of residence: ______________________________________________________

Part III. The following documents are attached to 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 petitioners; ___  Preplacement evaluation on the petitioner(s); ___  Postplacement 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 by § 3-305(a)(10).

Part IV. Affidavit of Unavailable Information:

I, ____________________, after first being sworn, state that I am unable to provide the following information in Parts I, II or III:  ____________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ because the information is not known to me or not available to me after reasonable attempts to get it.

Dated at __________, this ___ day of __________, ___.

 ____________________, Petitioner

 ____________________, Petitioner

Subscribed and sworn to this ___ day of __________, ___.

before me,

 ____________________, Notary Public

Subscribed and sworn to this ___ day of __________, ___.

before me,

 ____________________, Notary Public

 [Former Form 131 deleted and Temporary Form 131 adopted effective July 1, 1996.  Amended and redesignated effective March 1, 1997; July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 131B Vermont Rules of Probate Procedure, Form 131B

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 131B. Petition to Adopt Minor by a Stepparent

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________  DOCKET NO. __________ IN RE: ADOPTION OF ___________________

PETITION TO ADOPT MINOR BY STEPPARENT


15A V.S.A. § 4-107

1. My Full Name Is: ___________________________________

2. My Date and Place of Birth Are:  ___________________

(Date) (Place)

3. The City or Town Where I Reside is: ________________

4.  My Mailing Address Is:  ______________________________

______________________________ ______________________________

5. The Length of Time I Have Lived at My Current Residence Is: _____________

6. My Relationship to the Minor Child Being Adopted Is: ____________________

7. My Occupation is: _______________________________________________________

8. My Approximate Income Is: _______________________________________________

9. I State That I Do Have the Facilities and Resources to Provide for the

 Care and Support of the Minor.

10. My Spouse's Occupation Is: ______________________________________________

11. My Spouse's Approximate Income Is: ______________________________________

12. Full Birth Name, Or Legal Name of Minor Who Is Being Adopted:

 _________________________________________________________________________

13. Name by Which Minor Will be Known After Adoption:

 _________________________________________________________________________

14. Sex of the Minor Who Is Being Adopted: __________________________________

15. Date of Birth and Time (or Approximate Time) of Birth of Minor Who Is

 Being Adopted:  _________________________________________________________________________

16. Place of Birth of Minor Who Is Being Adopted: ___________________________

17. The Minor _____ Is or _____ Is Not (Check One) An Indian Child as Defined

 in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq.

18. The Following Is A Description And Estimate of Value of Any Known

 Property of the Minor:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

19. I state that to the best of my knowledge and belief, any law governing  interstate or intercountry placement which applies to this adoption has  been complied with.

20. Names and Mailing Addresses of the Biological Parents of the Person to be

 Adopted:  Name  Mailing Address  1. _____________________________  _______________________________________  _______________________________________  2. _____________________________  _______________________________________  _______________________________________

21. The Following Persons Have Executed a Consent, Relinquishment, Or A

 Disclaimer of Parental Interest With Respect to This Adoption:  Name  Relationship  Type of Document Executed  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

22. A Consent or Relinquishment From Each of the Following Persons, Whose

 Parental Relationship with the Minor Has Not Been Terminated, May Be  Required:  Name  Relationship  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

23. With Respect to the Persons Named in the Immediately Preceding Section,

 The Following Facts And Circumstances May Excuse The Lack of Their  Consents:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

24. I Have Either:

 _____ Filed a previous Petition to Adopt in another court. If so, the  disposition of the Petition was as follows:  _________________________________________________________________________  _________________________________________________________________________  _____ Not filed a previous Petition to Adopt in another court.

25. The Following Is A Description of Any Previous Court Order or Court

 Proceeding Known to Me Concerning Child Support for the Minor or  Concerning Custody of or Visitation With the Minor (Use Additional  Sheets, If Necessary):  Name of Court  Docket Number Type of Proceeding  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

26. My Marital Status Is: _____ Married _____ Single

27. If I Am Married:

 A. The Date of My Marriage Was: __________.  B. The Place of My Marriage Was: __________.  C. The Place of Birth of My Spouse Was: __________.  D. The Date of Birth of My Spouse Was: __________.  E. If My Spouse Is Incompetent, the Date When a Court Declared Him or Her  Incompetent Was: __________.

28. If My Spouse is Deceased:

 A. The Date of His or Her Death Was: __________.  B. The Place of His or Her Death Was: __________.  C. The Cause of His or Her Death Was: __________.

29. The Minor Child Has been Residing with Me and My Spouse Since: __________

 __________.

30. If the Minor Is Not in My and My Spouse's Physical Custody:

 A. The Reason Why We Do Not Have Physical Custody Is As Follows:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________  B. The Date We Intend To Obtain Physical Custody Is: ____________________ 31. My Spouse And I Have Had Legal Custody of the Minor Since _______________  The Circumstances Under Which We Obtained Legal Custody Are As Follows:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

32. I request that I be permitted to adopt the minor as my child.

33. I Request the Following Additional Relief From the Court:

 _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

34. I have attached to this petition an explanation of why any of the

 information requested in this petition has not been provided by me.

35. Names and Mailing Addresses of Living Maternal Grandparents:

 ______________________________  ______________________________  ______________________________  ______________________________  ______________________________  ______________________________

36. Names and Mailing Addresses of Living Paternal Grandparents:

 ______________________________  ______________________________  ______________________________  ______________________________  ______________________________  ______________________________

37. A Home Study:

 _____ is being prepared. The name and address of the preparer is:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

38. If a Home Study is Not Being Prepared, Are You Going to File a Request

 With This Court for Waiver of the Home Study?  ___ Yes ___ No

 Dated at __________, this ___ day of __________, ___.

___________________________________ Petitioner

Subscribed and Sworn to this ___ day of __________, ___.

___________________________________ Notary Public

IF PETITIONER IS MARRIED, PETITIONER'S SPOUSE MUST SIGN THE FOLLOWING, UNLESS THE SPOUSE HAS BEEN JUDICIALLY DECLARED INCOMPETENT:

 I, ____________________, the spouse of the petitioner, consent to the filing of this petition.

___________________________________ (signature) ___________________________________ (printed name)

 [Redesignated July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 131C Vermont Rules of Probate Procedure, Form 131C

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 131C. Petition to Adopt Minor by a Parent's Partner

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________  DOCKET NO. __________ IN RE: ADOPTION OF ___________________

PETITION TO ADOPT MINOR BY PARENT'S PARTNER


15A V.S.A. § 4-107

1. My Full Name Is: ___________________________________

2. My Date and Place of Birth Are:  ___________________

3. The City or Town Where I Reside is: ________________

4. My Mailing Address Is:  ___________________________________________________________

5. The Length of Time I Have Lived at My Current Residence Is: _____________

6. My Relationship to the Minor Child Being Adopted Is: ____________________

7. My Occupation is: _______________________________________________________

8. My Approximate Income Is: _______________________________________________

9. I State That I Do Have the Facilities and Resources to Provide for the

 Care and Support of the Minor.

10. My Partner's Occupation Is: _____________________________________________

11. My Partner's Approximate Income Is: _____________________________________

12. Full Birth Name, Or Legal Name of Minor Who Is Being Adopted:

 _________________________________________________________________________

13. Name by Which Minor Will be Known After Adoption:

 _________________________________________________________________________

14. Sex of the Minor Who Is Being Adopted: __________________________________

15. Date of Birth and Time (or Approximate Time) of Birth of Minor Who Is

 Being Adopted:  _________________________________________________________________________

16. Place of Birth of Minor Who Is Being Adopted: ___________________________

17. The Minor _____ Is or _____ Is Not (Check One) An Indian Child as Defined

 in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq.

18. The Following Is A Description And Estimate of Value of Any Known

 Property of the Minor:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

19. I state that to the best of my knowledge and belief, any law governing interstate or intercountry placement which applies to this adoption has  been complied with.


20. Names and Mailing Addresses of the Biological Parents of the Person to be  Adopted:  Name  Mailing Address  1. _____________________________  _______________________________________  _______________________________________  2. _____________________________  _______________________________________  _______________________________________

21. The Following Persons Have Executed a Consent, Relinquishment, Or A  Disclaimer of Parental Interest With Respect to This Adoption:  Name  Relationship  Type of Document Executed  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

22. A Consent or Relinquishment From Each of the Following Persons, Whose

 Parental Relationship with the Minor Has Not Been Terminated, May Be  Required:  Name  Relationship  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

23. With Respect to the Persons Named in section 22, The Following Facts And

 Circumstances May Excuse The Lack of Their Consents:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

24. I Have Either:

 _____ Filed a previous Petition to Adopt in another court. If so, the  disposition of the Petition was as follows:  _________________________________________________________________________  _________________________________________________________________________  _____ Not filed a previous Petition to Adopt in another court.


25. The Following Is A Description of Any Previous Court Order or Court  Proceeding Known to Me Concerning Child Support for the Minor or  Concerning Custody of or Visitation With the Minor (Use Additional  Sheets, If Necessary):  Name of Court  Docket Number Type of Proceeding  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

26. My Partner and I are joined in a Civil Union: _____ Yes _____ No

27. If my Partner and I are currently joined in Civil Union:

 A. The Date of My Civil Union Was: __________.  B. The Place of My Civil Union Was: __________.  C. The Place of Birth of My Partner Was: __________.  D. The Date of Birth of My Partner Was: __________.  E. If My Partner Is Incompetent, the Date When a Court Declared Him or  Her Incompetent Was: __________.

28. If My Partner is Deceased:

 A. The Date of His or Her Death Was: __________.  B. The Place of His or Her Death Was: __________.  C. The Cause of His or Her Death Was: __________.

29. The Minor Child Has been Residing with Me and My Partner Since: ___________________.

30. If the Minor Is Not in My and My Partner's Physical Custody:

 A. The Reason Why We Do Not Have Physical Custody Is As Follows:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________  B. The Date We Intend To Obtain Physical Custody Is: ____________________

31. My Partner And I Have Had Legal Custody of the Minor Since ______________

 The Circumstances Under Which We Obtained Legal Custody Are As Follows:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

32. I request that I be permitted to adopt the minor as my child.

33. I Request the Following Additional Relief From the Court:

 _________________________________________________________________________  _________________________________________________________________________

34. I have attached to this petition an explanation of why any of the

 information requested in this petition has not been provided by me.


35. Names and Mailing Addresses of Living Maternal Grandparents:  __________________________________  _____________________________________  _____________________________________  __________________________________  _____________________________________  _____________________________________

36. Names and Mailing Addresses of Living Paternal Grandparents:

 __________________________________  _____________________________________  _____________________________________  __________________________________  _____________________________________  _____________________________________

37. A Home Study:

 _____ is being prepared. The name and address of the preparer is:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

38. If a Home Study is Not Being Prepared, Are You Going to File a Request

 With This Court for Waiver of the Home Study?  _____ Yes _____ No

 Dated at __________, this ___ day of __________, ___.

___________________________________ Petitioner

Subscribed and Sworn to this ___ day of __________, ___.

___________________________________ Notary Public

IF PETITIONER IS MARRIED, PETITIONER'S SPOUSE MUST SIGN THE FOLLOWING, UNLESS THE SPOUSE HAS BEEN JUDICIALLY DECLARED INCOMPETENT:

 I, ____________________, the spouse of the petitioner, consent to the filing of this petition.

___________________________________ (signature) ___________________________________ (printed name)

 [Adopted July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 136 Vermont Rules of Probate Procedure, Form 136

Form 136. Adoption Decree

STATE OF VERMONT PROBATE COURT DISTRICT OF _______________, SS DOCKET NO. _______

ADOPTION DECREE


15A V.S.A. § 3-705


 The court has considered a petition for adoption of the minor, ______________________________, filed under Title 15A V.S.A. (The Adoption Act);  and, based upon the evidence submitted at a hearing held on the _____ day of _______________, _____, makes the following findings:

1. The original name of the minor adoptee, or the minor's original initials are _____________________________________________________________________.

2. The said minor was born on the _____ day of _______________, _____, at _____ (A.M./P.M.), in ______________________________.

3. A petition for adoption of the said minor was duly filed by ______________________________ on the _____ day of _______________, _____.

4. The said petitioner ( ) is ( ) is not married, and is not a stepparent of the adoptee.

5. It ( ) has ( ) has not been duly requested that a new birth certificate be issued by the Supervisor of Vital Records with the following information therein set forth:

Father:  Name: ________________________________________________________  Date and Place of Birth: _____________________________________ Mother:  Maiden Name: _________________________________________________  Name by which mother is known: _______________________________  Date and Place of Birth: _____________________________________

6. The petition requests that the adoptee be known by the name of ______________________________ upon the issuance of this decree.

7. The adoptee has been in the physical custody of the petitioner for at least 180 days.

8. Notice of this proceeding for adoption has been served or dispensed with as to those persons entitled to receive notice under Part 4 of Article 3 of The Adoption Act.

9. Each necessary consent, relinquishment, waiver, disclaimer of parental interest, judicial order terminating parental rights, including any order issued under Part 5 of Article 3 of The Adoption Act, all as required by the Adoption Act, has been filed with the court.

10. Any evaluation required by The Adoption Act has been filed and considered by the court.

11. Each petitioner is a suitable adoptive parent for the minor.

12. All applicable requirements of The Adoption Act governing an interstate or intercountry placement for this adoption have been met.

13. The Indian Child Welfare Act, 25 U.S.C. § 1901 et seq., is not applicable to this proceeding;  or, if applicable, its requirements have been met.

14. The accounting and affidavit required by § 3-702 of The Adoption Act has been reviewed by the court, and the court has denied, modified or ordered reimbursement of any payment or disbursement that is not authorized under Article 7 of The Adoption Act.

15. The petitioner has received each report required by § 2-105 of The Adoption Act.

16. The court further finds as follows:

 Based upon the foregoing, the court finds that it is in the best interest of the said minor to grant the petition for adoption.

 Upon this decree becoming final, all parental rights and duties of each former parent of the adoptee are terminated, and the adoptive parent and the adoptee shall have the legal relationship of parent and child.  The effect of this decree shall be as provided in 15A V.S.A. §§ 1-104, 1- 105 and 1-106.  Any prior order or agreement for visitation or communication with the minor is now unenforceable.

 Any obligation to pay child support in the future will be terminated by the filing of a final consent to the adoption with the Family Court which ordered the child support and with the Vermont Office of Child Support (if applicable).  Any outstanding child support arrearage will not be vacated by this decree.  A written agreement concerning child support arrearages may be made by the Obligor and the Obligee and filed with the court which issued the child support order.  In the event that a child support arrearage is owed to the Office of Child Support Services, the consent of that office must be obtained as part of any agreement to waive arrearages.

 THEREFORE, it is hereby ORDERED AND DECREED that the said minor, ______________________________, is adopted by and made the child of ______________________________, and shall hereafter bear the name of ______________________________.

 Dated at ______________________________, Vermont, this _____ day of _______________, _____.

___________________________________ Probate Judge District of _________


 [Adopted effective July 1, 1996.  Amended and redesignated effective March 1, 1997; amended July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 136A Vermont Rules of Probate Procedure, Form 136A

Form 136A. Adoption Decree-Stepparent Adoption of a Minor

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________  Docket No. __________

IN RE ADOPTION OF ____________________

ADOPTION DECREE--STEPPARENT ADOPTION OF A MINOR


15A V.S.A. § 4-101 et seq.


 The Court has considered a petition for adoption of the above name minor filed under Title 15A V.S.A. (The Adoption Act).  Based upon the documents on file and the evidence submitted at a hearing held on __________, __________, the Court makes the following findings of fact:

1. The original name of the minor adoptee is:_____________________________________________________.

2. A petition for adoption of the said minor was filed by ____________________ on __________, _____.

3. The said minor was born on __________, _____ at __________. The time of birth was _____ (A.M./P.M.).

4. The said petitioner _____ is _____ is not married.

5. The said petitioner is a stepparent of the adoptee or is a person who is treated as a stepparent of the adoptee pursuant § 4-101(b) of The  Adoption Act. 6. Check one:

 _____ A new birth certificate shall not be issued because either the petitioner, or the minor, who is over the age of 14 years of age, has  requested that a new birth certificate not be issued.  _____ A new birth certificate shall be issued by the Supervisor of Vital  Records with the following information set forth therein:  Father: Name: _______________________________________  Date of Birth: ______________________________  Place of Birth: _____________________________  Mother: Maiden Name: ________________________________  Name by Which Mother is Known: ______________  _____________________________________________  Date of Birth: ______________________________  Place of Birth: _____________________________

7. The adoptee shall be known by the name of ____________________ upon the  issuance of this decree.

8. The adoptee has been in the physical custody of the petitioner for at least 180 days.

9. Notice of this proceeding for adoption has been served or dispensed with as to those parents entitled to receive notice under Part 4 of Article  3 of The Adoption Act and § 4-109 of The Adoption Act.

10. Each necessary consent, relinquishment, waiver, disclaimer of parental interest, judicial order terminating parental rights, including any  order issued under Part 5 of Article 3 of The Adoption Act, as required  by The Adoption Act, has been filed with the court.

11. Any evaluation required by The Adoption Act has been filed with, and considered by, the court or has not been required by the court pursuant  to § 4-110 of The Adoption Act.

12. The court has obtained the information required by § 2-203(d)(7)-(9) of The Adoption Act.

13. Each item required by § 3-305(a) of The Adoption Act, which the court has determined is relevant to this adoption has been filed with the court  or, if any of the said items is unavailable, the person responsible for  furnishing it has filed an affidavit explaining its absence.

14. All applicable requirements of The Adoption Act governing an interstate or intercountry placement for this adoption have been met.

15. The Indian Child Welfare Act, 25 U.S.C. § 1901 et seq., it is not applicable to this proceeding, or, if applicable, its requirements have  been met.

16. The accounting and affidavit required by § 3-702 of The Adoption Act have been reviewed by the court and the court has denied, modified, or  ordered reimbursement or any payment or disbursement which is not  authorized under Article 7 of The Adoption Act or the court has waived  the requirements of § 3-702 of The Adoption Act with respect to this  adoption.

17. The petitioner has received each report required by § 2-105 of The Adoption Act.

18. The petitioner is a suitable adoptive parent for the minor.

19. It is in the best interest of the minor to grant the petition for adoption.  

Upon this decree becoming final:  A. The legal relationship between the adoptive parent and the adoptee  shall be as set forth in § 1-104 of The Adoption Act.  B. The decree shall not affect: 1. the legal relationship between the parent who is the adoptive stepparent's spouse or deceased spouse and the adoptee shall remain the same as it was prior to the adoption; 2. an existing court order for visitation or communication with a minor adoptee by a person related to the adoptee through the parent who is the adoptive stepparent's spouse or deceased spouse; or 3. a court order or agreement for visitation or communication with a minor adoptee approved by the court pursuant to § 4-112 of The Adoption Act.  C. The legal relationship between the parent who is not the spouse or the  deceased spouse of the stepparent and the adoptee shall be as set forth  in § 1-105 of The Adoption Act,  EXCEPT THAT: 1. the minor and any descendant of the minor will retain rights of inheritance from and through this parent; and 2. a court order for visitation or communication with the minor by this parent or by a person related to the minor through this parent, or an agreement or order concerning another person which is approved by the court pursuant to § 4-112 of The Adoption Act survives the decree of adoption, but failure to comply with the terms of the order or agreement is not a ground for revoking or setting aside the adoption. 3. this parent remains liable for arrearages of child support unless released from that obligation by the other parent, and any guardian ad litem of the minor and any governmental entity providing public assistance to the minor.

 THEREFORE, it is hereby ORDERED AND DECREED that the said minor ____________________, is adopted by, and made the child of, ____________________ and shall hereafter bear the name of ____________________.

Dated this ___ date of __________, ___.

___________________________________ (signature) Probate Judge

 [Adopted effective January 21, 1997.  Redesignated effective March 2, 1998; amended July 2, 2004, effective October 1, 2004; redesignated July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 136B Vermont Rules of Probate Procedure, Form 136B

Form 136B. Adoption Decree--Partner Adoption of a Minor

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________  Docket No. __________

IN RE ADOPTION OF ____________________

ADOPTION DECREE--PARTNER ADOPTION OF A MINOR


15A V.S.A. § 3-705


 The Court has considered a petition for adoption of the above named minor filed under Title 15A V.S.A. (The Adoption Act).  Based upon the documents on file and the evidence submitted at a hearing held on __________, __________, the Court makes the following findings of fact:

1. The original name of the minor adoptee is:______________________________________________________________

2. A petition for adoption of the said minor was filed by ____________________ on __________, _____.

3. The said minor was born on __________, _____ at __________ The time of birth was _____ (A.M./P.M.).

4.  The said petitioner _____ is _____ is not married.

5. The said petitioner is a stepparent of the adoptee or is a person who is treated as a stepparent of the adoptee pursuant to Section 4-101(b) of  The Adoption Act. 6. Check one:

_____ A new birth certificate shall not be issued because either the petitioner, or the minor, who is over the age of 14 years of age, has requested that a new birth certificate not be issued. _____ A new birth certificate shall be issued by the Supervisor of Vital Records with the following information set forth therein: Father:  Name:

_________________________________________  Date of Birth: ________________________________  Place of Birth: _______________________________ Mother:  Name: _________________________________________  Name by Which Mother is Known: ________________  Date of Birth: ________________________________  Place of Birth: _______________________________

7. The adoptee shall be known by the name of ____________________ upon the issuance of this decree.

8. The adoptee has been in the physical custody of the petitioner for at least 180 days.

9. Notice of this proceeding for adoption has been served or dispensed with as to those persons entitled to receive notice under Part 4 of Article  3 of The Adoption Act and Section 4-109 of The Adoption Act.

10. Each necessary consent, relinquishment, waiver, disclaimer of parental interest, judicial order terminating parental rights, including any order issued under Part 5 of Article 3 of The Adoption Act, as required  by The Adoption Act, has been filed with the court.

11. Any evaluation required by The Adoption Act has been filed with, and considered by, the court or has not been required by the court pursuant  to Section 4-110 of The Adoption Act.

12. The court has obtained the information required by Section 2-203(d)(7)--(9) of The Adoption Act.

13. Each item required by Section 3-305(a) of The Adoption Act, which the court has determined is relevant to this adoption has been filed with  the court or, if any of the said items is unavailable, the person  responsible for furnishing it has filed an affidavit explaining its  absence.

14. All applicable requirements of The Adoption Act governing an interstate or intercountry placement for this adoption have been met.

15. The Indian Child Welfare Act, 25 U.S.C. Section 1901 et seq., is not applicable to this proceeding, or, if applicable, its requirements have  been met.

16. The accounting and affidavit required by Section 3-702 of The Adoption Act have been reviewed by the court and the court has denied, modified,  or ordered reimbursement of any payment or disbursement which is not  authorized under Article 7 of The Adoption Act or the court has waived  the requirements of Section 3-702 of The Adoption Act with respect to  this adoption.

17. The petitioner has received each report required by Section 2-105 of The Adoption Act.

18. The petitioner is a suitable adoptive parent for the minor.

19. It is in the best interest of

 the minor to grant the  petition for adoption.  Upon this decree becoming final:  A. The legal relationship between the adoptive parent and the adoptee  shall be as set forth in Section 1-104 of The Adoption Act;  B. The decree shall not affect:  1. an existing court order for  visitation or communication with a  minor adoptee by a person related to  the adoptee through the parent who is  the adoptive parent's spouse or  deceased spouse;  2. a court order or agreement for  visitation or communication with a  minor adoptee approved by the court  pursuant to Section 4-112 of The  Adoption Act.

 THEREFORE, it is hereby ORDERED AND DECREED that the said minor, ____________________, is adopted by, and made the child of, ____________________ and shall here after bear the name of ____________________.

Dated at __________ this ___ day of __________, ___.

___________________________________ (signature) Probate Judge

 [Redesignated and amended July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 139A Vermont Rules of Probate Procedure, Form 139A

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 139A. Consent of Parent Who Is Not Stepparent's Spouse (Non-Custodial Biological Parent)

STATE OF VERMONT  PROBATE COURT DISTRICT OF ____________  Docket No. __________

IN RE ADOPTION OF ____________________

 (a minor)

CONSENT OF PARENT WHO IS NOT STEPPARENT'S SPOUSE


(NON-CUSTODIAL BIOLOGICAL PARENT)


15A V.S.A. § 4-105


1. My Full Name ____________________ My Social Security # ______

2. My Mailing Address ________________________________________

________________________________________ ________________________________________

3. My Date of Birth ________________________________________

4. Full Name of Minor Who Is Being Adopted _________________________________

5. Date of Birth of Minor Who Is Being Adopted _____________________________

6. Full Name, Address and Telephone Number of the Attorney Representing the  Prospective Adoptive Parent(s) With Whom I have Placed, or Intend to  Place my Minor Child for Adoption:  _________________________________________________________________________  _________________________________________________________________________  _________________________________________________________________________

7. I understand that the adoption will terminate completely every aspect of the legal relationship that I have with the minor child except for  arrearages child support.

8. I understand that the adoption will remain valid whether or not any agreement for visitation or communication with the minor is later  performed.

9. I acknowledge that I have received a copy of this consent.

10. If I am a parent who is a minor, I have been advised by an attorney who is not representing an adoptive parent in this proceeding.

11. If I am a parent who is an adult, I have been informed of my rights to have an attorney who is not representing an adoptive parent in the  adoption proceedings.

12. I have been informed, before executing this consent, of the meaning and consequences of adoption, the availability of personal counseling and  legal counseling, the consequences of misidentifying the other parent,  the procedure for releasing information about the health and other  characteristics of the parent which may affect the physical or  psychological wellbeing of the minor who is being adopted, and the  procedure for release of the parents' identity pursuant to Article 6 of  15A V.S.A.

13. I have been advised of my obligation to provide information under 15A

 V.S.A. § 2-105 concerning disclosure of background information about  the minor, the minor's parents, and the extended family.

14. I have provided the person seeking to adopt my minor child with the information required by 15A V.S.A. § 2-105 concerning disclosure of  background information about the minor, the minor's parents, and the  extended family.

15. I understand that personal counseling is available to me by a certified  adoption counselor or other counselor of my choice.

16. I have been informed that it is the best interest of my minor child to

 keep the court informed of my current address and any family health  problems which I develop or I become aware of which could affect my  child in order for the court to respond to any inquiry concerning my  child's medical or social history.

17. I acknowledge that I have not received or been promised any money or

 anything of value for this consent except for payments authorized by  15A V.S.A. Article 7 that are itemized on a schedule attached to this  consent.

18. I state that the minor child who is being adopted is not an Indian child

 as defined in the Indian Child Welfare Act, 25 U.S.C. Sections 1901 et  seq.

19. I voluntarily and unequivocally consent to the adoption of my minor child

 by the person who is seeking to adopt and to transfer to that person,  and his or her present spouse, any right I have to legal or physical  custody of the minor.

20. I understand and agree that the adoption will terminate my parental

 relationship to the minor child and will terminate any existing court  order for custody, visitation, or communication with the minor child,  but I understand and agree that notwithstanding the adoption:  A. the minor and any descendent of the minor will retain rights of  inheritance from and through me;  B. a court order for visitation or communication with the minor by me, or  by a person related to the minor through the other parent, or an  agreement or order concerning another person which is approved by the  court under 15A V.S.A. Section 4-112, survives the decree of adoption,  but failure to comply with the terms of the order or agreement is not a  ground for revoking or setting aside this consent or the adoption;  C. I shall remain liable for arrearages of child support unless released  from that obligation by the other parent, and any guardian ad litem of  the minor and by a governmental agency providing public assistance to  the minor.

21. I do one of the following:

 _____ I waive notice to me of any further proceedings in the adoption of  my minor child unless the adoption is contested, appealed, or denied.  _____ I do not waive notice of any further proceedings in the adoption of  my minor child.

22. 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 ___ date of __________, ___ at __________ in the County of __________ and State of __________.

___________________________________ (signature) ___________________________________ (printed name)

STATE OF __________

COUNTY OF __________

 On ___ day of __________, ___, ____________________ personally appeared before me and signed or confirmed in my presence that he or she freely and voluntarily signed the above consent and acknowledged that the factual information set forth therein is true and correct to the best of his or her knowledge and belief.

 I am one of the following:

___ a Judge of a court that has jurisdiction over adoption proceedings in the State of

__________;

___ a person appointed by a Probate Judge to take consent or relinquishments;

___ a commissioned officer on active duty in the military service of the United States and the person signing the consent is in the military service;

___ an officer of the foreign service or a consular officer of the United States in another country, to wit:  __________, and the person executing this consent appeared before me in that country;

___ a person authorized to take acknowledgments.

___________________________________ (signature) ___________________________________ (printed name)

 [Adopted effective January 21, 1997.  Redesignated effective March 2, 1998; amended July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 139G Vermont Rules of Probate Procedure, Form 139G

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

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));

 (c) I am signing this consent voluntarily;

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

 (e) Before signing this consent, I have been informed of the meaning an 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;

 (c) received a copy of this consent;

 (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

 [Adopted effective January 21, 1997.  Redesignated effective March 2, 1998 and amended effective March 9, 1998; redesignated and amended July 2, 2004, effective October 1, 2004.]

 


Vt. R. Prob. P. Form 139K Vermont Rules of Probate Procedure, Form 139K

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 139K. Adoption Decree-Partner Adoption of a Minor

STATE OF VERMONT  PROBATE COURT DISTRICT OF __________  DOCKET NO.

IN RE: ADOPTION OF ________________________________________________

ADOPTION DECREE-PARTNER ADOPTION OF A MINOR

15A V.S.A. § 3-705

 The Court has considered a petition for adoption of the above named minor filed under Title 15A V.S.A. (The Adoption Act).  Based upon the documents on file and the evidence submitted at a hearing held on _______________, 1991 ___, the Court makes the following findings of fact:

1. The original name of the minor adoptee is: ________________________________.

2. A petition for adoption of the said minor was filed by ____________________  _______________________________________________________________________________ on _______________, _____.

3. The said minor was born on __________, 1991 ___ at ____________________.  The time of birth was __________ (A.M/P.M.).

4. The said petitioner ___ is ___ is not married.

5. The said petitioner is a stepparent of the adoptee or is a person who is treated as a stepparent of the adoptee pursuant to Section 4-101(b) of The Adoption Act.

6. Check one:

 _____ A new birth certificate shall not be issued because either the petitioner, or the minor, who is over the age of 14 years of age, has requested that a new birth certificate not be issued.

 _____ A new birth certificate shall be issued by the Supervisor of Vital Records with the following information set forth therein:

 Father: Name: ____________________________________________________  Date of Birth: ___________________________________________  Place of Birth: __________________________________________

 Mother: Maiden Name: _____________________________________________

 Name by Which Mother is Known: ___________________________ ___________________________________________________  Date of Birth: ___________________________________________  Place of Birth: __________________________________________

7. The adoptee shall be known by the name of _________________________________  _______________________________________________________________________________ upon the issuance of this decree.

8. The adoptee has been in the physical custody of the petitioner for at least 180 days.

9. Notice of this proceeding for adoption has been served or dispensed with as to those persons entitled to receive notice under Part 4 of Article 3 of The Adoption Act and Section 4-109 of The Adoption Act.

10. Each necessary consent, relinquishment, waiver, disclaimer of parental interest, judicial order terminating parental rights, including any order issued under Part 5 of Article 3 of The Adoption Act, as required by the Adoption Act, has been filed with the court.

11. Any evaluation required by The Adoption Act has been filed with, and considered by, the court or has not been required by the court pursuant to Section 4-110 of The Adoption Act.

12. The court has obtained the information required by Section 203(d)(7)-(9) of The Adoption Act.

13. Each item required by Section 3-305(a) of The Adoption Act, which the court has determined is relevant to this adoption has been filed with the court or, if any of the said items is unavailable, the person responsible for furnishing it has filed an affidavit explaining its absence.

14. All applicable requirements of The Adoption Act governing an interstate or intercountry placement for this adoption have been met.

15. The Indian Child Welfare Act, 25 U.S.C. Section 1901 et seq., is not applicable to this proceeding, or, if applicable, its requirements have been met.

16. The accounting and affidavit required by Section 3-702 of The Adoption Act have been reviewed by the court and the court has denied, modified, or ordered reimbursement of any payment or disbursement which is not authorized under Article 7 of The Adoption Act or the court has waived the requirements of Section 3-702 of the Adoption Act with respect to this adoption.

17. The petitioner has received each report required by Section 2-105 of The Adoption Act.

18. The petitioner is a suitable adoptive parent for the minor.

19. It is in the best interest of the minor to grant the petition for adoption.

 Upon this decree becoming final:

 A. The legal relationship between the adoptive parent and the adoptee shall be as set forth in Section 1-104 of The Adoption Act;

 B. The decree shall not affect:

 1. an existing court order for visitation or communication with a minor adoptee by a person related to the adoptee through the parent who is the adoptive parent's spouse or deceased spouse;  or

 2. a court order or agreement for visitation or communication with a minor adoptee approved by the court pursuant to Section 4-112 of The Adoption Act.

 THEREFORE, it is hereby ORDERED AND DECREED that the said minor,____________, is adopted by, and made the child of, ________________________________________ and shall hereafter bear the name of _________________________________________.

 Dated at ____________________ this _____ day of ____________________, _____.

___________________________________ (signature) Probate Judge

 [Adopted effective March 2, 1998. Amended July 2, 2004, effective October 1, 2004.]

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