Fill and Sign the Form 139c Consent of Agency in Nonstepparent Adoption

FORM 139C. CONSENT OF AGENCY IN NONSTEPPARENT ADOPTION STATE OF VERMONT PROBATE COURT DISTRICT OF _______________________ DOCKET NO. __________ IN RE: ADOPTION OF ___________________________________________________ CONSENT OF AGENCY IN NONSTEPPARENT 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: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6.I do one of the following: _____I waive notice to me or to my agency of any 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. Form 139C Page 2 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)