Form 128 - Relinquishment Of Minor To Agency For Adoption
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4FORM 128. RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION
STATE OF VERMONT
PROBATE COURT
DISTRICT OF ______________, SS
Docket No. ______________
IN RE THE ADOPTION OF____________________, A MINOR OF ___________________
________________________________________
RELINQUISHMENT OF MINOR TO AGENCY FOR 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 relinquish a child for adoption 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.
(2a) The full recorded name of the minor being relinquished for adoption 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 years). My relationship to the minor being relinquished is: ____________________
_____________________________ (parent, legal guardian, etc.) and I have authority to
relinquish this minor for adoption.
(2b) 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:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
(3) The name, address and telephone number of the adoption agency to which the relinquishment
is being made is:
Name: _______________________________________________________________________
Address: ____________________________________________________________________
_________________________________________________________________________
_______________________________________________________________________.
Telephone No. ____________________________.
10/04 SML
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