Fillable Form 139g. Consent To Adoption (Page 3 of 4) in pdf

(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)

Form 139g. Consent To Adoption Page 3