FORM 128. RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION STATE OF VERMONT DISTRICT OF ______________, SS PROBATE COURT Docket No. ______________ IN RE THE ADOPTION OF____________________, A MINOR OF ___________________ ________________________________________ RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION 15A V.S.A. § 2-406 NOW COMES the undersigned person, ________________________, and does swear or affirm under oath to the facts set forth herein and does relinquish a child for adoption as set forth in more detail below: (1) My full name is _______________________________________________________; my date of birth is _____________, my current mailing address is ________________________ ________________________________________; I am (check one) [ ] married; [ ] single and never married; [] single and divorced. (2a) The full recorded name of the minor being relinquished for adoption is _________________ _______________________________________; (circle one) his or her date of birth is ________________ and the time of birth was ____________ (A.M./P.M.). The minor is currently living at the following address: ____________________________________________ ________________________________, and has lived there for __________________ (weeks, months or years). My relationship to the minor being relinquished is: ____________________ _____________________________ (parent, legal guardian, etc.) and I have authority to relinquish this minor for adoption. (2b) The full name and address of the other parent is: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ The date of birth of the other parent is _______________________________; the other parent is (check one) [ ] married; [ ] single and never married; [ ] single and divorced. If the full name and address is not provided, please state the reason: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ (3) The name, address and telephone number of the adoption agency to which the relinquishment is being made is: Name: _______________________________________________________________________ Address: ____________________________________________________________________ _________________________________________________________________________ _______________________________________________________________________. Telephone No. ____________________________. 10/04 SML American LegalNet, Inc. www.FormsWorkflow.com (4) After careful consideration, I believe that it is the best interests of my said child to be placed for adoption. I am voluntarily and unequivocally consenting to the permanent transfer of legal and physical custody of the above minor to the above adoption agency for the purposes of adoption and to take any and all other measures that may be in the best interests of the minor. (5) I understand that I may revoke this relinquishment by notifying the court in which this relinquishment was signed, and the above adoption agency, in writing within 21 days after this relinquishment is executed that I wish to revoke this relinquishment. (I understand that if I and the above adoption agency agree, we may jointly revoke this relinquishment anytime before finalization of the adoption. If the adoption agency does not agree to revoke after the 21 day period has expired, then the relinquishment becomes irrevocable on the 22nd day after its execution.) I understand that if this relinquishment is obtained by fraud or duress, or if a condition which would permit revocation had occurred, then I may petition the court to have this relinquishment revoked. A motion to set aside this relinquishment on the basis of fraud, duress, or otherwise, would be filed in the ________________ District Probate Court located at ___________________________________________________. (6) I certify to the following: (a) I have read this relinquishment, or I have had it read to me; (b) English is my native language (if not, see 15A V.S.A. § 2-406(a)); (c) I am signing this relinquishment voluntarily; (d) I have received a copy of this relinquishment; (e) Before signing this relinquishment, I have been informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this relinquishment, my signing of this relinquishment and failure to revoke the relinquishment terminates any right I may have to object to the minor's adoption by the adoptive parent(s) as authorized by the agency. I also have been informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee. I have provided accurate information about the identity of the minor's other parent. I understand that when the child reaches the age of majority, he or she will be given information about my identity upon request unless I have signed a request for non-disclosure of identifying information. If I have signed such a request, I understand that I may withdraw it at any time; (f) If I am a minor, I certify that I was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ________________________________________ and he or she is present as this relinquishment is being executed; (g) If I am an adult, I certify that I was informed of my right to have an attorney represent me in this matter who is not representing the adoptive parent or representing the adoption agency to which the child is being relinquished; (h) I have provided to the agency nonidentifying information and information about the child's and my family's health history and background as required by 15A V.S.A. § 2-105, and I understand that before adoption becomes final, if information becomes available to me which was unavailable previously, then I have an obligation to provide this information; (i) I have been made aware that it is in the best interest of the adoptee that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop which could affect the child so that the court or agency may respond to any inquiry concerning the adoptee's medical or social history; I have also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee. I have been made aware of the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption American LegalNet, Inc. www.FormsWorkflow.com Act. (j) I have not received or been promised any money, or anything of value, in exchange for my executing this relinquishment except for payments which are authorized under 15A V.S.A. § 7-103 and which are itemized on an attachment to this relinquishment; I (circle one) have/have not been 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 Child Welfare Act, 25 U.S.C. § 1901 et seq. (l) That I (choose one) [ ] waive notice of any proceeding for adoption of the adoptee; [ ] waive notice of the adoption unless the adoption is contested, appealed or denied; [ ] do not waive notice of any proceeding for adoption and I would 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 or communication with the minor unenforceable; (n) I understand that after this relinquishment has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2-409, then the relinquishment becomes final and may not be revoked or set aside for any reason, including the failure of the adoptive parent or agency to permit me to visit or communicate with the minor adoptee. I further understand that this relinquishment will extinguish all parental rights and obligations, and the adoption will completely terminate every aspect of the legal relationship which I may have concerning the minor, except for arrearages of child support. (o) That before executing this relinquishment I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling. (7) If this relinquishment is being made conditional upon other conditions which are authorized under 15A V.S.A. § 2-406(e), then those conditions are set forth with particularity here. (If none, so state.) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ (8) I (circle one) have/have not participated as a party, witness, or in any other capacity in any litigation or action concerning the custody or support of the above-named minor in Vermont or any other state. I (circle one) have/have no information concerning any prior custody proceeding (including adoption, guardianship, divorce or paternity actions) concerning the minor which are pending or have been completed. I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of this child. (Any affirmative answer in this paragraph requires a description of the action or claim, including the court and docket number if available.) I swear that the factual information set forth in this relinquishment is true and correct to the best of my knowledge and belief. Dated this ____ day of______, _____, at ______________, County of __________________, and State of _____________________________________. ________________________________________________ (signature) ________________________________________________ (typed or printed name) American LegalNet, Inc. www.FormsWorkflow.com CERTIFICATION The Relinquishment of Minor For Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. § 2-405. Those facts set forth in the relinquishment were sworn to, under oath or affirmation, and I hereby certify that I explained to the person executing the relinquishment the contents and consequences of the relinquishment, and to the best of my knowledge or belief, the person executing the relinquishment: (a) read this relinquishment, or had it read to them; (b) signed this relinquishment voluntarily; (c) received a copy of this relinquishment; (d) was informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee; (e) if a minor, the minor signing the relinquishment was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is __________________________ and he was present as this relinquishment was executed; (f) if an adult, the person was informed of his or her right to have an attorney represent them in this matter who is not representing the adoptive parent or representing the adoption agency to which the child is being relinquished; (g) if a mother who has not identified a biological father, then the mother responded to inquiries as provided for under 15A V.S.A. § 3-404; (h) if a parent is deceased, then the person signing the relinquishment has provided the names and addresses of the persons described in 15A V.S.A. § 3-401(a)(6); (i) the person understands that personal counseling was available by a certified adoption counselor, or other counselor, of his or her choice; (j) I have received a statement from the adoption agency indicating an acceptance of the relinquishment as required in 15A V.S.A. § 2-405(f). (k) The person signing this relinquishment has also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee and the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act. Dated this ____ day of ______, _____, at ______________, County of __________________, and State of _____________________________________. _______________________________________________ (signature) ________________________________________________ (printed name) of Judge or other person authorized under statute American LegalNet, Inc. www.FormsWorkflow.com