Fillable Form 139g. Consent To Adoption (Page 2 of 4) in pdf

(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));

(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.

Form 139g. Consent To Adoption Page 2

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