700 - 00139A Consent of Non - Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) ( 0 4/2017 ) Page 1 of 3 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In re Adoption of: CONSENT OF N ON - C USTODIAL B IOLOGICAL P ARENT TO A DOPTION (Stepparent or Partner Adoption) 15A V.S A. 247 4 - 104 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 Non - Custodial Biological Parent 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: Information 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 certify that the following statement s are true : ( C heck the B ox if the S tatement is T rue. L eave the Box E mpty , if the Statement is Not True .) I have read this conse nt or I have had it read to me. I have been informed about the meaning and consequences of adoption. I understand that the adoption will terminate completely every aspect of the legal relationship I have with the minor child except for arrearages of child support. I understand that the adoption will remain valid whether or not any agreement for visitation or communication with the minor is later performed. I am a minor and I certify that I was advised by an attorney who is not representing the adoptive parent(s) or the adoption agency to which the child is being relinquished. The name of the attorney who gave me advice is and he or she is present as this consent is being executed. ( D o N ot C heck T his B ox if Y ou are an A dult) American LegalNet, Inc. www.FormsWorkFlow.com 700 - 00139A Consent of Non - Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) ( 0 4/2017 ) Page 2 of 3 I am an adult and I certify that I was informed of my right to have an attorney represent me in this matter, specifically an attorney who is not representing the adoptive parent or the adoption agency to which the child is be ing relinquished; ( D o N ot C heck T his B ox if Y ou are a M inor) Before executing this Consent, I was informed of the availability of personal counseling by a certified adoption counselor or other counselor of my choice. I have been informed about the consequences of misidentifying the other parent of this child. I have been advised of my obligation to provide information concerning disclosure of background nded family. I have provided the person seeking to adopt my child with non - identifying information about the law ( 15A V.S.A. 247 2 - 105). I understand that before the adoption becomes final, if information becomes available to me which was previously unavailable, then I have an obligation to provide this information. I have been informed of the procedure for releasing information about the health and other characteristics of the pa rent which may affect the physical or psychological well - being of the minor. 15A V.S.A. I have been informed that it is in the best inte rests of the minor child that I keep t he court informed of my current address an d any family health problems which may develop and which could affect the history. I have not received or been promised any money, or anything of value, in exchange for my exe cuting this consent except for payments which are authorized by law (15A V.S.A. 2477 - 103). These payments are itemized on an attachment to this consent. The minor child is an Indian child as defined by the federal Indian Ch ild Welfare Act. I under stand and agree that the adoption will terminate my parental relationship to the minor child and will terminate any existing court order for custody, visitation, or communication with the minor child. Notwithstanding the adoption, I agree that : The m inor and any descendant of the minor will retain rights of inhe ritance from and through myself. The court may approve an agreement for visitation or communication with the minor after the adoption if the court determines the agreement is in the best i nterests of the minor. Failure comply with the agreement is not grounds for revoking the consent or setting aside the adoption. I will remain liable for arrearages of child support, unless released from that obligation by the other parent and/or a governmental agency providing financial assistance for the support of the minor. American LegalNet, Inc. www.FormsWorkFlow.com 700 - 00139A Consent of Non - Custodial Biological Parent to Adoption (Stepparent or Partner Adoption) ( 0 4/2017 ) Page 3 of 3 With respect to notice of further proceedings related to this adoption : (C heck One Box Only) I waive notice of any proceeding for adoption of the minor; I w aive no tice of the adoption unless the adoption is contested, appealed or denied; I do not waive notice of the proceedings related to this adoption. I would like to be notified at the address in paragraph 1 of this Consent. Voluntary Consent: I voluntarily and unequivocally consent to the adoption of my minor child by the person who is seeking to adopt and to the transfer to that person, and his or her present spouse, any right I have to legal o r physical custody. I swear or affirm that the f acts set forth in this consent are true and correct to the best of my knowledge and belief. Date At: Signature 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