Form 139b. Consent Of Guardian Or Agency In Stepparent Adoption
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139B. C
G
A
S
A
ORM
ONSENT OF
UARDIAN OR
GENCY IN
TEPPARENT
DOPTION
STATE OF VERMONT
PROBATE COURT
DISTRICT OF _______________
DOCKET NO. _________
IN RE: ADOPTION OF _______________________________________________________
CONSENT OF GUARDIAN OR AGENCY IN STEPPARENT ADOPTION
15A V.S.A. § 4-106
1.
My Full Name _____________________________________________________________
2.
My Mailing Address ____________________________________________________
____________________________________________________
____________________________________________________.
3.
My Date of Birth __________________________________________.
4.
Full Name of Minor Who Is Being Adopted ____________________________________.
5.
Date of Birth of Minor Who Is Being Adopted ____________________________.
6.
Full Name, Address and Telephone Number of the Attorney Representing the
Prospective Adoptive Parent(s) With Whom I have Placed, or Intend to Place my Minor Child
for Adoption:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
7.
I am either:
_____ A. the Guardian of the above-named minor child and my consent is required for the
adoption of the minor; or
_____ B. a duly authorized representative of an agency whose consent is required for the
adoption of the minor child. The agency name and address is as follows:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
8.
I, or my agency, obtained the authority to consent to the adoption in the following
manner:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
9.
I understand and agree that the adoption will not terminate the parental relationship between
the minor and the parent who is living with the stepparent.
10.
I understand and agree that the adoption will terminate the parental relationship between the
minor and the parent who is not living with the stepparent.
11.
I understand and agree that the adoption will terminate any existing court order for custody,
visitation or communication with the minor but
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