FORM 125A. CONSENT TO ADOPTIONSTATE OF VERMONT PROBATE COURTDISTRICT OF , SS DOCKET NO.IN RE THE ADOPTION OF , A MINOROF CONSENT TO ADOPTION 15A V.S.A. 247 2-406NOW COMES the undersigned person, ,and does swear or affirm under oath to the facts set forth herein and does consent to the adoptiondescribed herein as set forth in more detail below:(1) My full name is ; my date of birth is ; mycurrent mailing address is ; I am(check one) G married; G single and never married; G single and divorced.(2) The full name of the minor to be adopted is :(circle one) his or her date of birth is and the time of birthwas (A.M./P.M.). The minor is currently living at the following address:,and has lived there for (weeks, months or years).(3a) The name and address of the adoptive parents are known to me and their name(s) and addressis as follows (Please give the names, addresses and telephone numbers, if available, or if unavailableor unknown to you, please give whatever information you have):.The name of the attorney representing the prospective adoptive parent(s) is: and his or her address and telephone number is: .(3b)The full name and address of the other parent is:If full name and address is not provided, please state the reason: American LegalNet, Inc. www.FormsWorkFlow.com Form 125A Page 2 (4) I am voluntarily and unequivocally consenting to the transfer of legal and physical custodyto, and adoption of, the above-named minor child by the proposed adoptive parent(s) who Ihave selected and who are identified in paragraph #3 above. I further believe that theadoption of the minor is in the minor's best interest.(5) I understand that I may revoke this consent by notifying the court in writing within 21 days afterthis consent is executed that I wish to revoke this consent. (I understand that if I and the prospectiveparents agree, we may jointly revoke this consent anytime before finalization of the adoption. If theprospective adoptive parents do not agree to revoke after the 21 day period then the consent becomesirrevocable on the 22nd day after its execution.) I understand that if this consent is obtained by fraudor duress, or if an adoption petition is not filed within 45 days after the minor was placed foradoption without good cause, then I may petition the court to have this consent revoked. Thepetition may be filed in the court in which the adoption is pending, if known, or in the court in whichthis consent is signed.(6) The name and address of the court in which the adoption petition has been filed, or will be filed,is: . Ifunknown, the name and address of the court in which a motion to set aside this consent on the basisof fraud, duress or otherwise, would be filed is: District ProbateCourt located at .(7) I certify to the following:(a) I have read this consent, or I have had it read to me;(b) English is my native language (if not, see 15A V.S.A. 247 2-406(a));(c) I am signing this consent voluntarily;(d) I have received a copy of this consent;(e) Before signing this consent, I have been informed of the meaning and consequences ofadoption. I understand that, unless otherwise provided in this consent, my signing of thisconsent and failure to revoke the consent terminates any right I may have to object to theminor's adoption by the prospective adoptive parent(s). I also have been informed about theconsequences of misidentifying the other parent of this child and the procedure for releasinginformation about health, characteristics, and identity of myself to the adoptee;(f) If I am a minor, I certify that I was advised by an attorney who is not representing theadoptive parent or the adoption agency to which the child is being relinquished; the name ofthe attorney is and he or she is present as thisconsent is being executed;(g) If I am an adult, I certify that I was informed of my right to have an attorney representme in this matter who is not representing the adoptive parent or representing the adoptionagency to which the child is being relinquished;(h) I have provided to the adoptive parents, or their agent, nonidentifying information andinformation about the child's and my family's health history and background as required by15A V.S.A. 247 2-105, and I understand that before the adoption becomes final, if informationbecomes available to me which was unavailable previously, then I have an obligation toprovide this information; American LegalNet, Inc. www.FormsWorkFlow.com Form 125A Page 3 (i) I have been made aware that it is in the best interests of the adoptee that I keep the courtor the adoption agency informed of my current address and any family health problems ofmine which may develop which could affect the child so that the court or agency mayrespond to any inquiry concerning the adoptee's medical or social history. I have also beenmade aware of the procedure for releasing information about the health and othercharacteristics of the parent which may affect the physical or psychological well-being of theadoptee and the procedure for release of the parent's identity pursuant to Article 6 of theVermont Adoption Act.(j) I have not received or been promised any money, or anything of value, in exchange formy executing this consent except for payments which are authorized under 15A V.S.A. 247 7-103 and which are itemized on an attachment to this consent; I (circle one) have/have notbeen a recipient of public assistance during the last 12 months;(k) The minor child (circle one) is/is not an Indian Child as defined in the Indian ChildWelfare Act, 25 U.S.C. 247 1901 et seq.(l) That I (chose one)G waive notice of any proceeding for adoption of the adoptee;G waive notice of the adoption unless the adoption is contested,appealed or denied;Gdo not waive notice of any proceeding for adoption and Iwould like to be notified at my address as set forth above;(m) I understand that the adoption will make any orders or agreements for visitation orcommunication with the minor unenforceable;(n) I understand that after this consent has been executed in compliance with 247 2-405 andnot revoked in compliance with 247 2-408 or 247 2-409, then the consent becomes final and maynot be revoked or set aside for any reason, including the failure of the adoptive parent oragency to permit me to visit or communicate with the minor adoptee. I further understandthat this consent will extinguish all parental rights and obligations, and the adoption willcompletely terminate every aspect of the legal relationship which I may have concerning theminor, except for arrearages of child support.(o) That before executing this consent I was informed of the availability of personalcounseling by a certified adoption counselor, or other counselor of my choice and legalcounseling.(8) If this consent is being made conditional upon other conditions which are authorized under 15AV.S.A. 247 2-406(e), then those conditions are set forth with particularity here. (If none, so state.)(9) I (circle one) have/have not participated as a party, witness, or in any other capacity in anylitigation or action concerning the custody or support of the above-named minor in Vermont or anyother state. I (circle one) have/have no knowledge of any person or adoption agency or state agencywho has physical or legal custody of the child, or who claims to have custody or visitation rights withthis child. (Any affirmative answer in this paragraph requires a description of the action or claim,including the court and docket number if available.) American LegalNet, Inc. www.FormsWorkFlow.com Form 125A Page 4 I swear that the factual information set forth in this consent is true and correct to the best ofmy knowledge and belief.Dated this day of , 19, at ,County of , and State of .(signature)(typed or printed name)CERTIFICATION The Consent to Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. 247 2-405. Those facts set forth in the consent were sworn to, under oath or affirmation, and I herebycertify that I explained to the person executing the consent the contents and consequences of theconsent, and to the best of my knowledge or belief, the person executing the consent:(a) read this consent, or had it r