Fill and Sign the Relinquishment of Minor to Agency for Adoption Vermont Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) RELINQUISHMENT PETITION Part I. The undersigned petitioner represents as follows: That the petitioner is the recipient of a child pursuant a written relinquishment signed within 15 days prior to the date of this petition. The written relinquishment is attached to this petition. A certificate of consent or non- consent to disclosure identifying information also is attached. That the name, address and date of birth of the child are as follows: Name , Date of Birth ___________________________________ ___________________________________ Current Address That the age of the mother of the child is       , the age of the father of the child is       . That the petitioner is the Department of Social and Rehabilitation Services or a licensed child placing agency. That the petitioner requests that the court terminate the parental rights of ___________________________________ , ___________________________________ the natural parent(s) of the child, pursuant to the written relinquishment signed by that person or persons. Part II. Persons Interested in Relinquishment Petition The undersigned petitioner represents that the following are the names and addresses of the persons interested in the above entitled relinquishment proceeding as far as are known to the petitioner. I. Parent or parents who have signed the written relinquishment or surrender: Name Address _________________________ _________________________ _________________________ _________________________ II. Parent who has not signed the written relinquishment or surrender: Name Address _________________________ _________________________ _________________________ _________________________ III. Maternal grandparents of the child if the mother is a minor: Name Address _________________________ _________________________ _________________________ _________________________ IV. Paternal grandparents of the child if the father is a minor and is married to the mother of the child or has acknowledged paternity of the child. Name Address _________________________ _________________________ _________________________ _________________________ Dated ____________ Signed _____________________ , petitioner ________________________________________________________ Agency Name (if applicable) ________________________________________________________ Print Name ________________________________________________________ Address ________________________________________________________ I, __________________ , after first being sworn, state that I am unable to provide the name of __________________ in the above listing because the information is not known to me or to the agency on whose behalf I have prepared this list and the parent who signed the written relinquishment refuses or is unable to provide the information. Subscribed and sworn to this ____ day of ___________ ,20 ___ . Before me, __________________________________________________________ Notary Public Note that this form must be completed under oath if any name or address is omitted. Rev.3/1/89