Fill and Sign the Consent of Stepparents Spouse Form

10/04 SMLFORM 139. CONSENT OF STEPPARENT'S SPOUSE (BIOLOGICAL PARENT) STATE OF VERMONT PROBATE COURT DISTRICT OF ______________ Docket No. __________ IN RE ADOPTION OF __________________________________________ (a minor) CONSENT OF STEPPARENT'S SPOUSE (BIOLOGICAL PARENT)15A V.S.A. § 4-404 1. My Full Name _____________________________________________________ 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 state that I have legal and physical custody of my above-named minor child. I voluntarily and unequivocally consent to the adoption of my said minor child. 8. I understand and agree that the adoption will not terminate the relationship of parental relationship between my minor child and me. 9. I understand and agree that the adoption will terminate the relationship of parent and child between my minor child and the minor child's other parent. 10. I understand and agree that the adoption will terminate any existing court order for custody, visitation, or communication with the minor child. 11. I understand and agree that notwithstanding the adoption: A. the minor and any descendent of the minor will retains rights of inheritance from and through the minor's other parent; B. a court order for visitation or communication with the minor by me, or by a person related to the minor through me, or an agreement or order concerning another person which is approved by the court under 15A V.S.A. § 4-112, survives the decree of adoption, but failure to comply with the terms of the order or agreement is not a ground for revoking or setting aside this consent orthe adoption; C. the other parent remains liable for arrearages of child support unless relieved of that obligation by me, and any guardian ad litem of the minor and by a governmental agency providing public assistance to the minor. 12. This consent is not, and cannot be, a waiver of any further notice to me of the proceeding for adoption of the minor child by the person seeking to adopt. 13. 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 true and correct to the best of his orher 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 o fficer of the United States in another country, to wit: __________________, and the person executing this consent appeared before me in that country; __ a person authorized to take acknowledgments. __________________________________________ (signature) __________________________________________ (printed name)