Fill and Sign the Consent of Parent Who is Not Stepparents Spouse Pc 139a Form

10/04 SMLFORM 139A. CONSENT OF PARENT WHO IS NOT STEPPARENT'S SPOUSE (NON-CUSTODIAL BIOLOGICAL PARENT) STATE OF VERMONT PROBATE COURT DISTRICT OF ______________ Docket No. _____________________ IN RE ADOPTION OF ____________________________________________________ (a minor) CONSENT OF PARENT WHO IS NOT STEPPARENT'S SPOUSE (NON-CUSTODIAL BIOLOGICAL PARENT) 15A V.S.A. § 4-105 1. My Full Name _______________________ My Social Security # ______________ 2. My Mailing Address ____________________________________________________ ____________________________________________________ ____________________________________________________ 3. My Date of Birth ____________________________________________________ 4. Full Name of Minor Who Is Being Adopted ___________________________________ 5. Date of Birth of Minor Who Is Being Adopted _________________________________ 6. Full Name, Address and Telephone Number of the Attorney Representing the Prospective Adoptive Parent(s) With Whom I have Placed, or Intend to Place my Minor Child for Adoption: _________________________________________________________________ __________________________________________________________________________________________________________________________________ 7. I understand that the adoption will terminate completely every aspect of the legal relationship that I have with the minor child except for arrearages child support. 8. I understand that the adoption will remain valid whether or not any agreement for visitation or communication with the minor is later performed. 9. I acknowledge that I have received a copy of this consent. 10. If I am a parent who is a minor, I have been advised by an attorney who is not representing an adoptive parent in this proceeding. 11. If I am a parent who is an adult, I have been informed of my rights to have an attorney who is not representing an adoptive parent in the adoption proceedings. 12. I have been informed, before executing this consent, of the meaning and consequences ofadoption, the availability of personal counseling and legal counseling, the consequences of misidentifying the other parent, the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological wellbeing of the minor who is being adopted, and the procedure for release of the parents' identity pursuant to Article 6 of 15A V.S.A. 13. I have been advised of my obligation to provide information under 15A V.S.A. § 2-105 concerning disclosure of background information about the minor, the minor's parents, and the extended family. 14. I have provided the person seeking to adopt my minor child with the information required by 15A V.S.A. § 2-105 concerning disclosure of background information about the minor, the minor's parents, and the extended family. 15. I understand that personal counseling is available to me by a certified adoption counselor or other counselor of my choice. 16. I have been informed that it is the best interest of my minor child to keep the court informed of my current address and any family health problems which I develop or I become aware of which could affect my child in order for the court to respond to any inquiry concerning my child's medical or social history. 17. I acknowledge that I have not received or been promised any money or anything of value for this consent except for payments authorized by 15A V.S.A. Article 7 that are itemizedon a schedule attached to this consent. 18. I state that the minor child who is being adopted is not an Indian child as defined in the Indian Child Welfare Act, 25 U.S.C. Sections 1901 et seq. 19. I voluntarily and unequivocally consent to the adoption of my minor child by the person who is seeking to adopt and to transfer to that person, and his or her present spouse, any right I have to legal or physical custody of the minor. 20. I understand and agree that the adoption will terminate my parental relationship to the minor child and will terminate any existing court order for custody, visitation, or communication with the minor child, but I understand and agree that notwithstanding the adoption : A. the minor and any descendent of the minor will retain rights of inheritance from and through me; B. a court order for visitation or communication with the minor by me, or by a person related to the minor through the other parent, or an agreement or order concerninganother person which is approved by the court under 15A V.S.A. Section 4-112, survives the decree of adoption, but failure to comply with the terms of the order or agreement isnot a ground for revoking or setting aside this consent or the adoption; C. I shall remain liable for arrearages of child support unless released from thatobligation by the other parent, and any guardian ad litem of the minor and by a governmental agency providing public assistance to the minor. 21. I do one of the following: ____ I waive notice to me of any further proceedings in the adoption of my minor child unless the adoption is contested, appealed, or denied. ____ I do not waive notice of any further proceedings in the adoption of my minor child. 22. 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 ________ date of ______________, _____ at __________________ in the County of __________________ and State of __________________. __________________________________________ (signature) __________________________________________ (printed name) STATE OF ____________________ COUNTY OF __________________ On ________ day of ______________, _____, __________________ personally appeared before me and signed or confirmed in my presence that he or she freely and voluntarily signed the above consent and acknowledged that the factual information set forth therein is trueand correct to the best of his or her knowledge and belief. I am one of the following: __a Judge of a court that has jurisdiction over adoption proceedings in the State of__________________; __ a person appointed by a Probate Judge to take consent or relinquishments; __ a commissioned officer on active duty in the military service of the United States and the person signing the consent is in the military service; __ an officer of the foreign service or a consular officer of the United States in another country, to wit: __________________, and the person executing this consent appeared before me in thatcountry; __ a person authorized to take acknowledgments. __________________________________________(signature) __________________________________________ (printed name)