STATE OF VERMONT SUPERIOR COURT Unit In re Adoption of: RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION I swear or affirm under oath that the facts set forth below are true and I voluntarily relinquish my child for adoption. My Information: Full Name: ______________________________________________________________________ Date of Birth: _____________________________ Place of Birth: ____________________________ Mailing Address (town, state, zip): ______________________________________________________________ Phone Number: _____________________________ I am: Single/Never Married Married In a Civil Union Single/Divorced Spouse/Partner Deceased My native language is: English Other (specify) _______________________________ Information about the Minor Child to be Adopted: Minor's Full Name: ______________________________________________________________________ Date of Birth: _____________________________ Time of Birth: ____________________________ Name of Person(s) with Whom Minor Resides: __________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Minor has lived at this address for ________ Weeks Months Years My relationship to this child is Parent Legal Guardian Yes Other ____________ No I have authority to relinquish this child for adoption PROBATE DIVISION Docket No. Information about the Other Parent: provide all information that you know about Name of Other Parent: ____________________________________________________________________ Other Parent's Date of Birth: ___________________________ Mailing Address (town, state, zip): ______________________________________________________________ Phone Number: _____________________________ Marital Status: Married Never Married Divorced Don't Know I do not know some or all of the information about the other parent because: ______________________________________________________________________________________ ______________________________________________________________________________________ Information about the adoption agency: Name(s) of Agency: ____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Phone Number: _____________________________ 700-00128 ­ Relinquishment of Minor to Agency for Adoption (07/2016) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 1. Voluntary Consent: After careful consideration, I believe that it is in the best interests of my child to be placed for adoption. I voluntarily and unequivocally consent to the transfer of legal and physical custody of this minor child to the above named adoption agency for the purposes of adoption and to take any and all measures that may be in the best interests of the child. 2. Revocation of Consent: I understand that: a) I may revoke this consent by notifying the court and the adoption agency in writing that I wish to revoke this consent. I understand that my written notice to revoke must be delivered to the court within 21 days after this consent is signed or on or before this date: _______________________ 21 days from date consent is signed b) If the adoption agency and I agree, we may jointly revoke this consent any time before finalization of the adoption. However, if the adoption agency does not agree to revoke after the 21 day period, then this consent will become irrevocable on the 22nd day after it was signed; and c) If this consent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days after the minor is placed for adoption, without good cause, then I may petition the court to have this consent revoked. The petition may be filed in either the court in which the adoption is pending or in the court where the consent is signed. 3. I certify that the following statements are true: the box empty.) (check each box if the statement is true. If the statement is not true, leave I have read this consent or I have had it read to me; I am signing this consent voluntarily; Before signing this consent, I was informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this consent, my signing of this consent and failure to timely revoke the consent, terminates any right I may have to object to the minor's adoption by the prospective adoptive parent(s). I have been informed about the consequences of misidentifying the other parent of this child; I have been informed about the procedure for releasing information about health, characteristics, and identity of myself to the adoptee; I am a minor and I certify that I was advised by an attorney who is not representing the adoptive parent(s) or the adoption agency to which the child is being relinquished. The name of the attorney who gave me advice is _________________________ and he or she is present as this consent is being executed; (do not check this box if you are an adult.) I am an adult and I certify that I was informed of my right to have an attorney represent me in this matter, specifically an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; (do not check this box if you are a minor.) I have provided to the adoptive parent(s), or their agent, non-identifying information about the child's and my family's health history and background as required by law (15A V.S.A. §2-105). I understand that before the adoption becomes final, if information becomes available to me which was previously unavailable, then I have an obligation to provide this information. I have been informed that it is in the best interests of the minor child that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop and which could affect the child. This will allow the court or agency to respond to any inquiries concerning the minor's medical or social history. I have been informed 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 minor and the legal procedure for release of the parent's identity. 700-00128 ­ Relinquishment of Minor to Agency for Adoption (07/2016) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4  I have not received or been promised any money, or anything of value, in exchange for my executing this cons