700-00131A 226 Petition to Adopt Adult (11/2018) Page 1 of 4 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of: PETITION TO ADOPT AN ADULT 15A V.S A. 2475-105 I/We, the undersigned petitioner(s), state as follows: Part I - General Information Information About the Person to be Adopted: Full Name Date of Birth: Place of Birth: Complete Mailing Address: Marital Status: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married, state the date and place of marriage: Name by which Adult will be known after adoption: Request for New Birth Certificate: Petitioners have requested that a new birth certificate be issued by the Supervisor of Vital Records that includes the name, date of birth, and place of birth of the adoptive parent(s) as set forth below: Prospective Adoptive Parent A Information: Full Name Prospective Adoptive Parent A: Date of Birth: Place of Birth: Maiden Name: Complete Mailing Address: Town & State of Residence: Length of Residence at Current Address: Phone Number: I am: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married, state the date and place of marriage: American LegalNet, Inc. www.FormsWorkFlow.com 700-00131A 226 Petition to Adopt Adult (11/2018) Page 2 of 4 Prospective Adoptive Parent B Information: Full Name Prospective Adoptive Parent B: Date of Birth: Place of Birth: Maiden Name: Complete Mailing Address: Town & State of Residence: Length of Residence at Current Address: Phone Number: I am: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married, state the date and place of marriage: State the Duration and Nature of the relationship between the Adoptee and Adoptive Parents: Part II - Certifications by Petitioners The prospective adoptive parent(s) and the adoptee certify as follows: 1. The prospective adoptive parent(s) and the adoptee desire to assume the legal relationship of parent and child and to have all of the rights and be subject to all of the duties of that relationship. 2. The adoptee understands that a consequence of the adoption will be to terminate the adoptee's relationship as the child of an existing parent, but if the adoptive parent is the adoptee's stepparent, the adoption will not affect the adoptee's relationship with a parent who is the stepparent's spouse, but will terminate the adoptee's relationship to the adoptee's other parent, except for the right to inherit from or through that parent. 3. The adoptee and the prospective parent(s) understand the consequences the adoption may have for any right of inheritance, property, or support from adoptive and biological parents. Part III - Persons Interested in Adoption Proceeding Full Name and last known address of any other person whose consent to this adoption is required: Full Name: Complete Mailing Address: Town & State of Residence: Full Name: Complete Mailing Address: Town & State of Residence: Full Name: Complete Mailing Address: Town & State of Residence: American LegalNet, Inc. www.FormsWorkFlow.com 700-00131A 226 Petition to Adopt Adult (11/2018) Page 3 of 4 Full Name, age and last known address of each biological or adopted child of the prospective adoptive parents. If adopted, state the date and place of adoption Full Name: Age: Complete Mailing Address: Adoption Information, if any: Full Name: Age: Complete Mailing Address: Adoption Information, if any: Full Name: Age: Complete Mailing Address: Adoption Information, if any: Full Name: Age: Complete Mailing Address: Adoption Information, if any: Full Name: Age: Complete Mailing Address: Adoption Information, if any: Name. age and last known address of each living parent or child of the adoptee Full Name: Age: Complete Mailing Address: Full Name: Age: Complete Mailing Address: Part IV - Documents Attached to the Petition The following documents must be attached to the petition: Certified copy of Adoptee222s birth certificate Certified copy of birth certificate for each adoptive parent Any required consent that has been executed1 Filing Fee I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. On: Date At: Signature of Petitioner, Adoptive Parent A City, County and State Printed Name 1 The only required consent to the adoption of an adult or emancipated minor is the consent of the spouse or civil union partner of the prospective adoptive parent. (Form # PA139e) American LegalNet, Inc. www.FormsWorkFlow.com 700-00131A 226 Petition to Adopt Adult (11/2018) Page 4 of 4 I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. On: Date At: Signature of Adoptee City, County and State Printed Name I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. On: Date At: Signature of Petitioner, Adoptive Parent B City, County and State Printed Name Signed and sworn to before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com