Vt. Stat. tit. 15A § 2-406
Title Fifteen (A). Adoption Act
Aarticle 2. Adoption of Minors
Part 4. Consent to and Relinquishment for Adoption
§ 2-406 Content of consent or relinquishment
(a) A consent or relinquishment required from a parent or guardian under this title shall be in writing and contain, in plain English or, if the native language of the parent or guardian is a language other than English, in that language:
(1) the name, date of birth, and current mailing address of the individual executing the consent or relinquishment;
(2) the date of birth and the name of the minor adoptee;
(3) if a consent, the name, address, and telephone number of the attorney representing the prospective adoptive parent with whom the individual executing the consent has placed or intends to place the minor for adoption;
(4) if a relinquishment, the name, address, and telephone number of the agency to which the minor is being relinquished;
(5) specific instructions as to how to revoke the consent or relinquishment and how to commence an action to set it aside;
(6) the name and address of the court, if known to the parent, in which the petition for adoption has been or will be filed, or if unknown to the parent, the name and address of a court in which a motion to set aside a consent on the ground of fraud or coercion may be filed.
(b) A consent shall state that the parent or guardian executing the document is voluntarily and unequivocally consenting to the transfer of legal and physical custody to, and the adoption of the minor by, a specific adoptive parent whom the parent or guardian has selected.
(c) A relinquishment shall state that the individual executing the relinquishment voluntarily consents to the permanent transfer of legal and physical custody of the minor to the agency for the purposes of adoption.
(d) A consent or relinquishment shall state:
(1) an understanding that after the consent or relinquishment is executed in substantial compliance with section 2-405 of this title, it is final and, except under a circumstance stated in sections 2-408, 2-409 of this title, or subsection (e) of this section may not be revoked or set aside for any reason, including the failure of an adoptive parent to permit the individual executing the consent or relinquishment to visit or communicate with the minor adoptee;
(2) an understanding that the consent or relinquishment will extinguish all parental rights and obligations the individual executing the consent or relinquishment has with respect to the minor adoptee;
(3) an understanding that the adoption will terminate completely every aspect of the legal relationship between the adoptee and the person executing the consent or relinquishment has with respect to the minor adoptee, except for arrearages of child support, and will remain valid whether or not any agreement for visitation or communication with the minor adoptee is later performed;
(4) that the individual executing the consent or relinquishment has:
(A) received a copy of the consent or relinquishment;
(B) been advised, if a parent who is a minor, by an attorney who is not representing an adoptive parent or the agency to which the minor adoptee is being relinquished, or, if an adult, has been informed of the right to have an attorney who is not representing an adoptive parent or the agency;
(C) been provided the information described in subsection 2-404(e) of this title;
(D) been advised of the obligation to provide the information required under section 2-105 of this title;
(E) if a parent, understands that personal counseling was available by a certified adoption counselor or other counselor of his or her choice; and
(F) been informed that it is in the best interest of the child to keep the court or agency informed of his or her current address and any family health problem which the parent develops or becomes aware of which could affect the child, in order for the court or agency to respond to any inquiry concerning the adoptee's medical or social history;
(5) that the individual executing the consent or relinquishment has not received or been promised any money or anything of value for the consent or the relinquishment, except for payments authorized by Article 7 of this title that are itemized on a schedule attached to the consent or relinquishment;
(6) that the minor is or is not an Indian child as defined in the Indian Child Welfare Act, 25 U.S.C. Sections 1901 et seq.;
(7) that the individual believes the adoption of the minor is in the minor's best interest;
(8) that the individual who is consenting or relinquishing:
(A) does not waive notice of any proceeding for adoption; or
(B) waives notice of any proceeding for adoption; or
(C) waives notice unless the adoption is contested, appealed or denied; and
(9) an understanding that the adoption will make an order or agreement for visitation or communication with the minor unenforceable; and
(10) for the purpose of evaluating the reasonableness of reimbursement or expenses as provided for in section 7-103 of this title, whether the individual executing the consent or relinquishment has received any public assistance during the last 12 months.
(e) A consent or relinquishment may provide for its revocation if:
(1) another consent or relinquishment is not executed within a specified period;
(2) a court decides not to terminate another individual's parental relationship to the minor; or
(3) in a direct placement for adoption, a petition for adoption by a prospective adoptive parent, named or described in the consent, is denied or withdrawn.
-- Added 1995, No. 161 (Adj. Sess.), § 1.