Fill and Sign the Petition to Adopt Minor Child Form

STATE OF VERMONT SUPERIOR COURT Unit PROBATE DIVISION Docket No. In re Adoption of: PETITION TO ADOPT MINOR CHILD I/We ask the Court to permit me/us to adopt the minor child named above. I/We swear or affirm under oath that the facts set forth below are true to the best of my/our knowledge and belief: Part I - General Information Information About the Minor Child to be Adopted: Full Birth or Current Legal Name: ___________________________________________________________ Date of Birth: _____________________________ Time of Birth: ____________________________ Name by which child will be known after adoption: ______________________________________________ Town & State where child was born: _________________________________________________________ Gender of Minor ☐ Male ☐ Female Describe any assets or property owned by the child and the value of each asset. Assets/Property Value __________________________________________________ $____________________________ __________________________________________________ $____________________________ __________________________________________________ $____________________________ Petitioner A Information: Full Name Petitioner A: _____________________________________________________________________ Date of Birth: _____________________________ Place of Birth: ____________________________ Last Name at Birth: _______________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town & State of Residence: ______________________________________________________________ Length of Residence at Current Address: ______________ Phone Number: ___________________________ Describe Your Relationship to the Child: ________________________________________________________ Occupation: ___________________________________ Annual Income: $__________________________ I have the resources and the facilities to provide care and support for this child. ☐ Yes ☐ No I am: ☐ Single/Never Married ☐ Married ☐ In a Civil Union ☐ Single/Divorced ☐ Spouse/Partner Deceased If married, has spouse been judicially determined to be incompetent? ☐ Yes ☐ No Date of most recent pre-placement evaluation: _________________________________________________ 700-00131 – Petition to Adopt Minor (06/2019) Page 1 of 5 Petitioner B Information: Full Name Petitioner B: _____________________________________________________________________ Date of Birth: _____________________________ Place of Birth: ____________________________ Last Name at Birth: _______________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town & State of Residence: ______________________________________________________________ Length of Residence at Current Address: ______________ Phone Number: ___________________________ Describe Your Relationship to the Child: ________________________________________________________ Occupation: ___________________________________ Annual Income: $__________________________ I have the resources and the facilities to provide care and support for this child. ☐ Yes ☐ No I am: ☐ Single/Never Married ☐ Married ☐ In a Civil Union ☐ Single/Divorced ☐ Spouse/Partner Deceased If married, has spouse been judicially determined to be incompetent? ☐ Yes ☐ No Date of most recent pre-placement evaluation: _________________________________________________ I state that to the best of my knowledge and belief, the minor ☐ is American heritage. (check appropriate box) ☐ is not Native American or of Native I state to the best of my knowledge and belief, any law governing interstate or inter-country placement which applies to this adoption has been complied with. Biological Parent A Information: provide all information that you know about Full Name Biological Parent A: _____________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Phone Number: ___________________________ Biological Parent B Information: provide all information that you know about Full Name Biological Parent B: _____________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Phone Number: ___________________________ ☐ I do not know some or all of the information about the other parent because: _____________________________________________________________________________________ Were the parents married at the time of the child’s birth? ☐ Yes ☐ No ☐ Don’t Know If no, were either or both of the parents married to someone else? ☐ Yes ☐ No ☐ Don’t Know Are the parents divorced? ☐ Yes ☐ No ☐ Don’t Know If yes, how was custody (parental rights) awarded? ☐ To Parent A ☐ To Parent B ☐ Jointly to Both ☐ Don’t Know Consent, Relinquishment or Disclaimer of Parental Interest: The following person(s) has/have signed a consent, relinquishment or disclaimer of parental interest: Name __________________________ __________________________ __________________________ 700-00131 – Petition to Adopt Minor (06/2019) Relationship to Child ______________________ ______________________ ______________________ Type of Document Signed _________________________ _________________________ _________________________ Page 2 of 5 The following person(s) has a parental relationship that has not been terminated and a consent or relinquishment may be required: Name __________________________ __________________________ __________________________ Relationship to Child ______________________ ______________________ ______________________ Facts that may explain Lack of Consent _________________________ _________________________ _________________________ Prior Adoption Petitions I have previously filed an adoption petition in another court: ☐ Yes ☐ No If yes, describe what happened to your petition: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Prior or Pending Court Proceedings Involving this Child Describe any Court proceedings or Court Orders related to this child concerning child support, custody (parental rights and responsibilities) or visitation (parent child contact). Use additional sheets if necessary Name of Court __________________________ __________________________ __________________________ Docket Number ______________________ ______________________ ______________________ Type of Court Proceeding _________________________ _________________________ _________________________ Current Residence of Minor Child ☐ The child has resided with the petitioner(s) since ______________________________. ☐ The child was placed with petitioner by an agency. The name and address of the agency is: __________________________________________________________________________________ ☐ The child was placed with petitioner by __________________________. The relationship between the child and this person is: __________________________________________________________. ☐ The child is not currently residing with the petitioner(s) because: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Legal Custody of Minor I/We have legal custody of the minor: ☐ Yes ☐ No If yes, describe the circumstances under which you obtained custody of the minor: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Home Study ☐ A home study is being prepared by: ________________________________________________________ Name and Address of Preparer ☐ I intend to request a waiver of the home study ☐ Yes ☐ No If you are requesting a waiver, you must attach a letter to the court explaining why a waiver would be appropriate 700-00131 – Petition to Adopt Minor (06/2019) Page 3 of 5 Part II - Persons Interested in Adoption Proceeding Mother of Child: Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Husband of Mother: (if the child was born during the marriage or within 300 days after its termination) Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Name of Biological Father Identified by Mother: Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Any Other Man who was not married to the mother at the time of the child’s birth, but has acknowledged paternity and has demonstrated a parental relation to the child and financial responsibility for the child: Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Name of the Child’s Legal Guardian: Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Name of the Agency or Person who placed child with petitioners: Full Name _____________________________________________________________________ Mailing Address (town, state, zip): ______________________________________________________________ Town of Residence: _____________________________________________________________________ Part III - Documents Attached to the Petition Petitioner(s) must make reasonable efforts to obtain the following documents and file them with the petition: A. Originals or Certified Copies of: █ Child's birth certificate or other record of date and place of birth; █ Any consent, relinquishment, order terminating parental rights or disclaimer of parental interest that have been executed; █ Written certification required of person before whom the consent or relinquishment was executed; █ Each parent or former parent's marriage certificate, decree of divorce, annulment or dissolution, or agreement of legal separation; █ Any court order determining the former parent's incompetence; █ Any existing court order or petition in a pending proceeding concerning custody of, or visitation or communication with, the child; █ Petitioner's marriage certificate, decree of divorce, annulment or agreement of legal separation; █ Any court order determining that the spouse of the petitioner is incompetent. B. Copies of: █ Birth certificates of petitioner(s); █ Pre-placement evaluation on the petitioner(s); 700-00131 – Petition to Adopt Minor (06/2019) Page 4 of 5 █ Post-placement evaluation; █ Report on the child and family's background information required by § 2-105; █ Any agreement with a public agency for adoption subsidy; █ Any collateral agreement between the petitioner and parent or guardian or any agency; █ Any request for nondisclosure signed by the parent or former parent. C. If an agency placed the child for adoption, a verified statement from the agency is required. [See 15A V.S.A. § 3-305(a)(10)] Part IV - Unavailable Information I am unable to provide the following information in Parts I, II or III of this petition because the information is not known to me or not available to me after a reasonable attempt to get it. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. On: At: Date Signature of Petitioner A City, County and State Printed Name I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. On: At: Date Signature of Petitioner B City, County and State Printed Name Signed and sworn to before me: Date Signature of Notary Public 700-00131 – Petition to Adopt Minor (06/2019) Expiration Date Page 5 of 5