FORM 127. STATEMENT OF DISCLOSURE OF IDENTIFYING INFORMATION
STATE OF VERMONT
PROBATE COURT
DISTRICT OF ______________, SS
Docket No. ______________
IN RE THE ADOPTION OF ______________________________________
STATEMENT OF DISCLOSURE OF IDENTIFYING INFORMATION
I hereby make the following statement regarding the release of my name and address to my child
should he or she request that information after the age of 18 or emancipation.
____ I consent to the release of identifying information.
____ I request that my name and address be kept confidential. I understand that a judge may
decide to release this information for very important reasons (i.e., medical reasons) even
though I have requested confidentiality.
Child’s full name: ______________________________________________________________
Date of birth: __________________________
Place of birth: _______________________
I understand that I may change my mind about the choice I made above at any time prior to the
release of identifying information by contacting the Adoption Registry, 103 South Main Street,
Waterbury, VT 05671-2401.
Parent’s full name: _____________________________________________________________
Date and Place of Birth: _________________________________________________________
Driver’s Licence #: _____________________________________________________________
Social Security #:_______________________________________________________________
Permanent Address: ____________________________________________________________
Telephone Number: ____________________________________________________________
Parent’s Signature: _____________________________________________________________
Sworn before me at ______________________ on this ______day of _________ , _______
______________________________________
My commission expires on _____________
Notary Public
10/04 SML
Original to Adoption Registry, Copy to Probate Court, Child’s Record