700-00131BC Petition to Adopt Minor by Stepparent () Page 1 of 4 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of: P ETITION TO ADOPT MINOR BY STEPPARENT O R D OMESTIC PARTNER OF CUSTODIAL PARENT I /We ask the Court to permit me /us to adopt the minor child named above. I /We swear or affirm under oath that the facts set forth below are true to the best of my knowledge and belief: Information A bout the M inor C hild to be A dopted ull Birth or Current Legal Na m e : Date of Birth: Time of Birth: AM PM Place of Birth (town, state, zip ) : Name by which Child will be known After Adoption: Gender of Child: Male Female Describe any assets or property owned by the child and the value of each asset Asset Value $ $ $ Petitioner Information My Name: Date of Birth: Place of Birth: Complete Mailing Address (town, state, zip ) : Length of time residing at this residence: Phone Number: Describe your relationship to the Child: Occupation: Annual Income: $ I have the resources and the facilities to provide the care and support for this Child: Yes No 1) I state that to the best of my knowledge and belief, the minor is not subject to the Indian Child Welfare Act, 25 U.S.C. 2471901 et seq. 2) I state to the best of my knowledge and belief, any law governing interstate or inter - country placement which app lies to this adoption has been complied with. American LegalNet, Inc. www.FormsWorkFlow.com 700-00131BC Petition to Adopt Minor by Stepparent () Page 2 of 4 Information A bout the B iological P arents - provide all information that you know Full Na m e of Parent A : Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : Full Na m e of Parent B : Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : I do not know some or all of the information about the other par ent because (briefly explain) : Consent , Relinquishment or Disclaimer of Parental Interest The following person ( s ) has/ have signed a consent, relinquishment or disclaimer of parental interest: Name Relationship to Child Type of Document Signed The following person ( s ) has a parental relationship that has not been terminated and a consent or relinquishment m ay be required: Name Relationship to Child Facts that may E xplain Lack of C onsent Prior Adoption Petitions I have previously filed an adoption petition in another court: Yes No If yes, describe what happened to your petition: Prior or Pending Court Proceedings Involving this Child Describe any Court proceedings or Court Orders related to this child concerning child support, custody (parental rights and responsibilities ) or visitation (parent child contact). Use additional shee ts if necessary Name of Court Docket Number Type of Court Proceeding American LegalNet, Inc. www.FormsWorkFlow.com 700-00131BC Petition to Adopt Minor by Stepparent () Page 3 of 4 Information R elated to M arital S tatus : Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married or in a Civil Union, complete the following information: Date of Marriage/Union: Place of Marriage/Union: Date of Birth: of Birt h: If married, has spouse been judicially de termined to be incompetent: Yes No If Yes, please provide the date of determination: If spouse/partner is deceased, please provide the following information: Date of Death: Place of Death: Cause of Death: Current Residence of Minor Child The child has resided with the petitioner since . The child is no t currently residing with petitioner b ecause: Legal Custody of Minor I/We have legal custody of the minor : Yes No If yes, describe the circumstances under which you obtained custody of the minor: Information ab out Living Maternal Grandparents Full Na m e of Living Maternal Gr andmother: Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : Phone Number: Full Na m e of Living Maternal Grandfather: If contact information for maternal grandfather is different than maternal grandmother, please complete the information below Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : Phone Number: American LegalNet, Inc. www.FormsWorkFlow.com 700-00131BC Petition to Adopt Minor by Stepparent () Page 4 of 4 Information about Living Paternal Grandparents Full Na m e of Living Paternal Grandmother: Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : Phone Num ber: Full Na m e of Living Paternal Grandfather: If contact information for maternal grandfather is different than maternal grandmoth er, please complete the information below Complete Mailing Address : Town & State of Residence: Mailing Address (if different) : Phone Number: Home Study A home study is being prepared by (name and address of preparer) : I request a waiver of the home study : Yes No If you are requesting a waiver, you must attach a letter to the Court explaining in detail why a waiver would be appropriate. I swear or affirm that the facts set forth in this consent are true and correct to the best of my knowledge and belief. On: Date At: Signature of P City, County and State Printed Name Signed and sworn to before me: S SPOUSE/PARTNER MUST CONSENT TO THE PETITION BY SIGNING BELOW UNLESS THE SPOUSE/PARTNER HAS BEEN JUDICIALLY DECLARED I NCOMPETENT. I am the spouse/part ner of the petitioner and I consent to the filing of this petition On: Date At: Signature of Spouse/Partner City, County and State Printed Name Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com