FORM 131B. PETITION TO ADOPT MINOR BY A STEPPARENT STATE OF VERMONT DISTRICT OF ______________ PROBATE COURT DOCKET NO. ____________________________ IN RE: ADOPTION OF ______________________________________ PETITION TO ADOPT MINOR BY STEPPARENT 15A V.S.A. § 4-107 1. My Full Name Is: ________________________________________________________ 2. My Date and Place of Birth Are: ____________________________________________ (Date) (Place) 3. The City or Town Where I Reside is: ________________________________________ 4. My Mailing Address Is: 5. The Length of Time I Have Lived at My Current Residence Is: ____________________ 6. My Relationship to the Minor Child Being Adopted Is: __________________________ 7. My Occupation is: _______________________________________________________ 8. My Approximate Income Is: _______________________________________________ 9. I State That I Do Have the Facilities and Resources to Provide for the Care and Support of the Minor. 10. My Spouse's Occupation Is: ________________________________________________ 11. My Spouse's Approximate Income Is: ________________________________________ 12. Full Birth Name, Or Legal Name of Minor Who Is Being Adopted: ______________________________________________________________________ 13. Name by Which Minor Will be Known After Adoption: ______________________________________________________________________ 14. Sex of the Minor Who Is Being Adopted: _____________________________________ 15. Date of Birth and Time (or Approximate Time) of Birth of Minor Who Is Being Adopted: _______________________________________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ 10/04 SML American LegalNet, Inc. www.FormsWorkflow.com 16. Place of Birth of Minor Who Is Being Adopted: ________________________________ 17. The Minor ____ Is or ____ Is Not (Check One) An Indian Child as Defined in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq. 18. The Following Is A Description And Estimate of Value of Any Known Property of the Minor: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 19. I state that to the best of my knowledge and belief, any law governing interstate or intercountry placement which applies to this adoption has been complied with. 20. Names and Mailing Addresses of the Biological Parents of the Person to be Adopted: Name Mailing Address 1. ________________________________ ___________________________________ ___________________________________ 2. ________________________________ ___________________________________ ___________________________________ 21. The Following Persons Have Executed a Consent, Relinquishment, Or A Disclaimer of Parental Interest With Respect to This Adoption: Name Relationship Type of Document Executed _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 22. A Consent or Relinquishment From Each of the Following Persons, Whose Parental Relationship with the Minor Has Not Been Terminated, May Be Required: Name Relationship _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 23. With Respect to the Persons Named in the Immediately Preceding Section, The Following Facts And Circumstances May Excuse The Lack of Their Consents: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 24. I Have Either: ____ Filed a previous Petition to Adopt in another court. If so, the disposition of the Petition was as follows: _______________________________________________________________________ _______________________________________________________________________ ____ Not filed a previous Petition to Adopt in another court. 25. The Following Is A Description of Any Previous Court Order or Court Proceeding American LegalNet, Inc. www.FormsWorkflow.com Known to Me Concerning Child Support for the Minor or Concerning Custody of or Visitation With the Minor (Use Additional Sheets, If Necessary): Name of Court Docket Number Type of Proceeding _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 26. My Marital Status Is: ____ Married ____ Single 27. If I Am Married: A. The Date of My Marriage Was: __________________ . B. The Place of My Marriage Was: __________________ . C. The Place of Birth of My Spouse Was: __________________ . D. The Date of Birth of My Spouse Was: __________________ . E. If My Spouse Is Incompetent, the Date When a Court Declared Him or Her Incompetent Was: __________________ . 28. If My Spouse is Deceased: A. The Date of His or Her Death Was: __________________ . B. The Place of His or Her Death Was: __________________ . C. The Cause of His or Her Death Was: __________________ . 29. The Minor Child Has been Residing with Me and My Spouse Since: ________________ __________________ . 30. If the Minor Is Not in My and My Spouse's Physical Custody: A. The Reason Why We Do Not Have Physical Custody Is As Follows: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ B. The Date We Intend To Obtain Physical Custody Is: __________________________ 31. My Spouse And I Have Had Legal Custody of the Minor Since ____________________ The Circumstances Under Which We Obtained Legal Custody Are As Follows: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 32. I request that I be permitted to adopt the minor as my child. 33. I Request the Following Additional Relief From the Court: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 34. I have attached to this petition an explanation of why any of the information requested in this petition has not been provided by me. American LegalNet, Inc. www.FormsWorkflow.com 35. Names and Mailing Addresses of Living Maternal Grandparents: __________________ _______________________________________________ _______________________________________________ __________________ _______________________________________________ _______________________________________________ 36. Names and Mailing Addresses of Living Paternal Grandparents: __________________ _______________________________________________ _______________________________________________ __________________ _______________________________________________ _______________________________________________ 37. A Home Study: ____ is being prepared. The name and address of the preparer is: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 38. If a Home Study is Not Being Prepared, Are You Going to File a Request With This Court for Waiver of the Home Study? ____ Yes ____ No Dated at ________________________________________ , this ________ day of ______________ , ______ . ________________________________________ Petitioner Subscribed and Sworn to this ________ day of ______________ , _____. ________________________________________ Notary Public IF PETITIONER IS MARRIED, PETITIONER'S SPOUSE MUST SIGN THE FOLLOWING, UNLESS THE SPOUSE HAS BEEN JUDICIALLY DECLARED INCOMPETENT: I, ________________________________________, the spouse of the petitioner, consent to the filing of this petition. ________________________________________ (signature) ________________________________________ (printed name) American LegalNet, Inc. www.FormsWorkflow.com