Fill and Sign the Consent of Agency in Nonstepparent Adoption Vermont Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) CONSENT OF AGENCY IN STEPPARENT ADOPTION 15A V.S.A. § 2-405(h) 1. I am a duly authorized representative of an agency whose consent is required for the adoption of the minor child. The agency name and address is as follows: ______________________________ ______________________________ ______________________________ 2. Full Name of Minor Who is Being Adopted: ____________________ 3. Date of Birth of Minor Who is Being Adopted: _______________ . 4. Full Name, Address and Telephone Number of the Attorney Representing the Prospective Adoptive Parent(s) With Whom the Agency Has Placed, or Intends to Place the Minor Child for Adoption: ______________________________ ______________________________ ______________________________ 5. I, or my agency, obtained the authority to consent to the adoption in the following manner: ______________________________ ______________________________ - 1 - ______________________________ 6. I do one of the following: I waive notice to me or to my agency of further proceedings in the adoption of the minor child unless the adoption is contested, appealed, or denied. I do not waive notice to me or to my agency of any further proceedings in the adoption of the minor child. 7. I state for myself and on behalf of my agency that I voluntarily and unequivocally consent to the adoption of the minor child. 8. I swear that the factual information set forth in this consent is true and correct to the best of my knowledge and belief. Dated this ____ day of ____________ , 20____ at _________________, in the County of _______________ and State of ________________ . _____________________________ (Signature) _____________________________ (Printed name) ______________________________ (Agency name) Signed and confirmed in the presence of the Judge or in the presence of a person directed by the Judge. _______________________________ (Signature) _______________________________ (printed name) ________________________________ (title) Rev.3/9/98 - 2 -