Probate Court Form 139F
Adoption Decree Stepparent
Adoption of a Minor
(Page 1 of 3)
STATE OF VERMONT
DISTRICT OF _______________________
IN RE ADOPTION OF _________________
DOCKET NO. ______________
ADOPTION DECREE - STEPPARENT ADOPTION OF A MINOR
15A V. S. A. 4-101 et seq.
The Court has considered a petition for adoption of the above-named minor filed under Title 15A
V. S. A. (The Adoption Act). Based upon the documents on file and the evidence submitted at a hearing held
on _______________________, 20 _____, the Court makes the following findings of fact:
1. The original name of the minor adoptee is:
2. A petition for adoption of the minor was filed by ______________________________
3. The minor was born on _______________, 20____ at _____________________.
The time of birth was _________________ (A.M./P.M.).
4. The petitioner _____ is _____ is not married.
5. The petitioner is a stepparent of the adoptee or is a person who is treated as a stepparent
of the adoptee pursuant to 4-101(b) of the Adoption Act.
6. Check one:
______ A new birth certificate shall not be issued because either the petitioner, or the
minor, who is over the age of 14, has requested that a new birth certificate not
______ A new birth certificate shall be issued by the Supervisor of Vital Records with
the following information set forth therein:
Father: Name: __________________________________
Date of Birth: _____________________________
Place of Birth: ____________________________
Mother: Maiden Name: ___________________________
Name by Which Mother is Known: __________________
Date of Birth : ___________________________________
Place of Birth: ___________________________________
7. The adoptee shall be known by the name of ________________
__________________________ upon issuance of this decree.
8. The adoptee has been in the physical custody of the petitioner for at least 180 days.