Fillable Form 139g. Consent To Adoption printable pdf download

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:

_____________________________________________________________________________

10/04 SML

Form 139g. Consent To Adoption