Form 128 - Relinquishment Of Minor To Agency For Adoption Page 2
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4(4) After careful consideration, I believe that it is the best interests of my said child to be
placed for adoption. I am voluntarily and unequivocally consenting to the permanent
transfer of legal and physical custody of the above minor to the above adoption agency for
the purposes of adoption and to take any and all other measures that may be in the best
interests of the minor.
(5) I understand that I may revoke this relinquishment by notifying the court in which this
relinquishment was signed, and the above adoption agency, in writing within 21 days after this
relinquishment is executed that I wish to revoke this relinquishment. (I understand that if I and
the above adoption agency agree, we may jointly revoke this relinquishment anytime before
finalization of the adoption. If the adoption agency does not agree to revoke after the 21 day
period has expired, then the relinquishment becomes irrevocable on the 22nd day after its
execution.) I understand that if this relinquishment is obtained by fraud or duress, or if a
condition which would permit revocation had occurred, then I may petition the court to have this
relinquishment revoked. A motion to set aside this relinquishment on the basis of fraud, duress,
or otherwise, would be filed in the ________________ District Probate Court located at
___________________________________________________.
(6) I certify to the following:
(a) I have read this relinquishment, or I have had it read to me;
(b) English is my native language (if not, see 15A V.S.A. § 2-406(a));
(c) I am signing this relinquishment voluntarily;
(d) I have received a copy of this relinquishment;
(e) Before signing this relinquishment, I have been informed of the meaning and consequences
of adoption. I understand that, unless otherwise provided in this relinquishment, my signing of
this relinquishment and failure to revoke the relinquishment terminates any right I may have to
object to the minor's adoption by the adoptive parent(s) as authorized by the agency. 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. I have provided accurate information about the identity of the minor's other parent. I
understand that when the child reaches the age of majority, he or she will be given information
about my identity upon request unless I have signed a request for non-disclosure of identifying
information. If I have signed such a request, I understand that I may withdraw it at any time;
(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
relinquishment 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 agency 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 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 interest 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. I have been made aware of
the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption
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