Form 139g. Consent To Adoption Page 4
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4CERTIFICATION
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
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