700 - 00139C - Consent to Adoption by Guardian or Agency (Non - Stepparent Adoption) ( 0 4/2017 ) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In re Adoption of: CONSENT TO ADOPTION BY GUARDIAN OR AGENCY (Non - Stepp arent Adoption) I swear or affirm under oath that the facts set forth below are true and I consent to the adoption of the minor child named below . Information about Guardian or Representative of Agency signing the Consent: My Name: Date of Birth: Address: Email Address: City/State/Zip: Daytime Phone: Name of Attorney: Address of Attorney: City/State/Zip: In formation about the M inor to be A dopted: Name: Date of Birth: Information about the Attorney Who R epresents the P rospective A doptive P arents: Name of Attorney: Phone: Address : City/State/Zip: I am: ( C heck O ne B ox O nly) t he G uardian of this minor and my consent is required for his/her adoption. a duly authorized representative of an agency whose consent is requir ed for the adoption of this minor . Information about the agency is as follows: Name of A gency : Phone: Address: City/State/ Zip: I, or my agency, obtained the authority to consent to the adoption in the following manner: ( Describe) American LegalNet, Inc. www.FormsWorkFlow.com 700 - 00139C - Consent to Adoption by Guardian or Agency (Non - Stepparent Adoption) ( 0 4/2017 ) Page 2 of 2 Waiver of Notice: ( C heck One B ox O nly) I w aive notice to m e or to m y a g ency of any further proceedin g s in the adoption of the m i nor child unless the adoption is contested, appealed, or denied. I do not w a i ve no ti ce to m e or to m y a g ency of any further proceedin g s in the adoption of the m i nor child. Voluntary Consent: I state for myself or on behalf of my agency that I voluntar ily and unequivocally consent to the adoption of this minor child . I swear or affirm that the facts set forth in this consent are true and correct to the best of my knowledge and belief. Date At: Signature of Guardian or Representative of Agency City, County and State Printed Name Signed and confirmed in the presence of the Judge or in the presence of a person directed by the Judge Date Signature Printed Name of Judge or Other Person Authorized by Judge American LegalNet, Inc. www.FormsWorkFlow.com