Fill and Sign the Vermont Stepparent Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) CONSENT OF GUARDIAN OR AGENCY IN STEPPARENT ADOPTION 15A V.S.A. § 4-106 1. My Full Name Name . 2. My Mailing Address ____________________ 3. My Date of Birth ____________________ . 4. Full Name of Minor Who Is Being Adopted Name . 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 am either: A. the Guardian of the above-named minor child and my consent is required for the adoption of the minor, or - 1 - B. 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: ____________________ ____________________ ____________________ 8. I, or my agency, obtained the authority to consent to the adoption in the following manner: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 9. I understand and agree that the adoption will not terminate the parental relationship between the minor and the parent who is living with the stepparent. 10. I understand and agree that the adoption will terminate the parental relationship between the minor and the parent who is not living with the stepparent. 11. If I understand and agree that the adoption will terminate any existing court order for custody, visitation or communication with the minor but A. the minor and any descendant of the minor will retain rights of inheritance from and through the parent of the minor who is not living with the stepparent; and B. a court order for visitation or communication with the minor by either parent, or by a person related to the minor through either parent, or an agreement or order concerning another 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 is not a ground for revoking or setting aside this consent or the adoption; C. the parent who is not living with the stepparent remains liable for arrearages of child support unless relieved of that obligation by the parent who lives with the stepparent, and any - 2 - guardian ad litem of the minor and by a governmental agency providing public assistance to the minor. 12. 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. 13. I state for myself or on behalf of my agency that I voluntarily and unequivocally consent to the adoption of the said minor child. 14. 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 _________________, 20______ at ______________ in the County of _________ and State of ____ . _______________________________ (signature) ________________________________ (printed name) ________________________________ (Agency name, if applicable) Signed and confirmed in the presence of the Judge or in the presence of a person directed by the Judge. ______________________________ (signature) _______________________________ (printed name) _______________________________ (title) Rev.3/1/97 - 3 -