700-00131 226 Petition to Adopt Minor (06/2019) Page 1 of 5 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of: PETITION TO ADOPT MINOR CHILD 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/our knowledge and belief: Part I - General Information Information About the Minor Child to be Adopted: Full Birth or Current Legal Name: Date of Birth: Time of Birth: Name by which child will be known after adoption: Town & State where child was born: Gender of Minor Male Female Describe any assets or property owned by the child and the value of each asset. Assets/Property Value $ $ $ Petitioner A Information: Full Name Petitioner A: Date of Birth: Place of Birth: Last Name at Birth: Mailing Address (town, state, zip): Town & State of Residence: Length of Residence at Current Address: Phone Number: Describe Your Relationship to the Child: Occupation: Annual Income: $ I have the resources and the facilities to provide care and support for this child. Yes No I am: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married, has spouse been judicially determined to be incompetent? Yes No Date of most recent pre-placement evaluation: American LegalNet, Inc. www.FormsWorkFlow.com 700-00131 226 Petition to Adopt Minor (06/2019) Page 2 of 5 Petitioner B Information: Full Name Petitioner B: Date of Birth: Place of Birth: Last Name at Birth: Mailing Address (town, state, zip): Town & State of Residence: Length of Residence at Current Address: Phone Number: Describe Your Relationship to the Child: Occupation: Annual Income: $ I have the resources and the facilities to provide care and support for this child. Yes No I am: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased If married, has spouse been judicially determined to be incompetent? Yes No Date of most recent pre-placement evaluation: I state that to the best of my knowledge and belief, the minor is is not Native American or of Native American heritage. (check appropriate box) I state to the best of my knowledge and belief, any law governing interstate or inter-country placement which applies to this adoption has been complied with. Biological Parent A Information: provide all information that you know about Full Name Biological Parent A: Mailing Address (town, state, zip): Phone Number: Biological Parent B Information: provide all information that you know about Full Name Biological Parent B: Mailing Address (town, state, zip): Phone Number: I do not know some or all of the information about the other parent because: Were the parents married at the time of the child222s birth? Yes No Don222t Know If no, were either or both of the parents married to someone else? Yes No Don222t Know Are the parents divorced? Yes No Don222t Know If yes, how was custody (parental rights) awarded? To Parent A To Parent B Jointly to Both Don222t Know 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 American LegalNet, Inc. www.FormsWorkFlow.com 700-00131 226 Petition to Adopt Minor (06/2019) Page 3 of 5 The following person(s) has a parental relationship that has not been terminated and a consent or relinquishment may be required: Name Relationship to Child Facts that may explain Lack of Consent 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 sheets if necessary Name of Court Docket Number Type of Court Proceeding Current Residence of Minor Child The child has resided with the petitioner(s) since . The child was placed with petitioner by an agency. The name and address of the agency is: The child was placed with petitioner by . The relationship between the child and this person is: . The child is not currently residing with the petitioner(s) because: 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: Home Study A home study is being prepared by: Name and Address of Preparer I intend to request a waiver of the home study Yes No If you are requesting a waiver, you must attach a letter to the court explaining why a waiver would be appropriate American LegalNet, Inc. www.FormsWorkFlow.com 700-00131 226 Petition to Adopt Minor (06/2019) Page 4 of 5 Part II - Persons Interested in Adoption Proceeding Mother of Child: Full Name Mailing Address (town, state, zip): Town of Residence: Husband of Mother: (if the child was born during the marriage or within 300 days after its termination) Full Name Mailing Address (town, state, zip): Town of Residence: Name of Biological Father Identified by Mother: Full Name Mailing Address (town, state, zip): Town of Residence: Any Other Man who was not married to the mother at the time of the child222s birth, but has acknowledged paternity and has demonstrated a parental relation to the child and financial responsibility for the child: Full Name Mailing Address (town, state, zip): Town of Residence: Name of the Child222s Legal Guardian: Full Name Mailing Address (town, state, zip): Town of Residence: Name of the Agency or Person who placed child with petitioners: Full Name Mailing Address (town, state, zip): Town of Residence: Part III - Documents Attached to the Petition Petitioner(s) must make reasonable efforts to obtain the following documents and file them with the petition: A. Originals or Certified Copies of: Child's birth certificate or other record of date and place of birth; Any consent, relinquishment, order terminating parental rights or disclaimer of parental interest that have been executed; Written certification required of person before whom the consent or relinquishment was executed; Each parent or former parent's marriage certificate, decree of divorce, annulment or dissolution, or agreement of legal separation; Any court order determining the former parent's incompetence; Any existing court order or petition in a pending proceeding concerning custody of, or visitation or communication with, the child; Petitioner's marriage certificate, decree of divorce, annulment or agreement of legal separation; Any court order determining that the spouse of the petitioner is incompetent. B. Copies of: Birth certificates of petitioner(s); Pre-placement evaluation on the petitioner(s); American LegalNet, Inc. www.FormsWorkFlow.com 700-00131 226 Petition to Adopt Minor (06/2019)Page 5 of 5 Post-placement evaluation; Report on the child and family's background information required by 247 2-105; Any agreement with a public agency for adoption subsidy; Any collateral agreement between the petitioner and parent or guardian or any agency; Any request for nondisclosure signed by the parent or former parent. C.If an agency placed the child for adoption, a verified statement from the agency is required. [See 15AV.S.A. 247 3-305(a)(10)] Part IV - Unavailable Information I am unable to provide the following information in Parts I, II or III of this petition because the information is not known to me or not available to me after a reasonable attempt to get it. 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 A 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 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