Native American Rights Fund, A Practical Guide to the Indian Child Welfare Act, Vermont Court Rules

Vt. R. Prob. P. Form 125A

Vermont Rules of Probate Procedure, Form 125A

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 125A. Consent to Adoption

STATE OF VERMONT PROBATE COURT

DISTRICT OF _______________.SS DOCKET NO. _______

IN RE THE ADOPTION OF ____________________, A MINOR OF ____________________

CONSENT TO ADOPTION

15A V.S.A. § 2-406

NOW COMES the undersigned person, ____________________, and does swear or affirm under oath to the facts set forth herein and does consent to the adoption described herein as set forth in more detail below:

(1) My full name is ____________________; my date of birth is __________; my current mailing address is ______________________________; I am (check one) ( ) married; ( ) single and never married; ( ) single and divorced.

(2) The full name of the minor to be adopted is ____________________: (circle one) his or her date of birth is __________ and the time of birth was _____ (A.M./P.M.). The minor is currently living at the following address: ______________________________, and has lived there for _______________ (weeks, months or years).

(3a) The name and address of the adoptive parents are known to me and their name(s) and address is as follows (Please give the names, addresses and telephone numbers, if available, or if unavailable or unknown to you, please give whatever information you have):

_______________________________________________________________________________

______________________________________________________________________________.

The name of the attorney representing the prospective adoptive parent(s) is: ______________________________ and his or her address and telephone number is: _________________________________________________________________________.

(3b) The full name and address of the other parent is:

_______________________________________________________________________________

If full name and address is not provided, please state the reason:

_______________________________________________________________________________

(4) I am voluntarily and unequivocally consenting to the transfer of legal and physical custody to, and adoption of, the above-named minor child by the proposed adoptive parent(s) who I have selected and who are identified in paragraph # 3 above. I further believe that the adoption of the minor is in the minor's best interest.

(5) I understand that I may revoke this consent by notifying the court in writing within 21 days after this consent is executed that I wish to revoke this consent. (I understand that if I and the prospective parents agree, we may jointly revoke this consent anytime before finalization of the adoption. If the prospective adoptive parents do not agree to revoke after the 21 day period then the consent becomes irrevocable on the 22nd day after its execution.) I understand that if this consent is obtained by fraud or duress, or if an adoption petition is not filed within 45 days after the minor was placed for adoption without good cause, then I may petition the court to have this consent revoked. The petition may be filed in the court in which the adoption is pending, if known, or in the court in which this consent is signed.

(6) The name and address of the court in which the adoption petition has been filed, or will be filed, is: _________________________________________________.

If unknown, the name and address of the court in which a motion to set aside this consent on the basis of fraud, duress or otherwise, would be filed is: _______________ District Probate Court located at _______________________.

(7) I certify to the following:

(a) I have read this consent, or I have had it read to me;

(b) English is my native language (if not, see 15A V.S.A. § 2-406(a));

(d) I have received a copy of this consent;

(e) Before signing this consent, I have been informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this consent, my signing of this consent and failure to revoke the consent terminates any right I may have to object to the minor's adoption by the prospective adoptive parent(s). I also have been informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee;

(f) If I am a minor, I certify that I was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is _________________________ and he or she is present as this consent is being executed;

(g) If I am an adult, I certify that I was informed of my right to have an attorney represent me in this matter who is not representing the adoptive parent or representing the adoption agency to which the child is being relinquished;

(h) I have provided to the adoptive parents, or their agent, nonidentifying information and information about the child's and my family's health history and background as required by 15A V.S.A. § 2-105, and I understand that before the adoption becomes final, if information becomes available to me which was unavailable previously, then I have an obligation to provide this information;

(i) I have been made aware that it is in the best interests of the adoptee that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop which could affect the child so that the court or agency may respond to any inquiry concerning the adoptee's medical or social history. I have also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee and the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

(j) I have not received or been promised any money, or anything of value, in exchange for my executing this consent except for payments which are authorized under 15A V.S.A. § 7-103 and which are itemized on an attachment to this consent; I (circle one) have/have not been a recipient of public assistance during the last 12 months;

(k) The minor child (circle one) is/is not an Indian Child as defined in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq.

(l) That I (chose one)

( ) waive notice of any proceeding for adoption of the adoptee;

( ) waive notice of the adoption unless the adoption is contested, appealed or denied;

( ) do not waive notice of any proceeding for adoption and I would like to be notified at my address as set forth above;

(m) I understand that the adoption will make any orders or agreements for visitation or communication with the minor unenforceable;

(n) I understand that after this consent has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2-409, then the consent becomes final and may not be revoked or set aside for any reason, including the failure of the adoptive parent or agency to permit me to visit or communicate with the minor adoptee. I further understand that this consent will extinguish all parental rights and obligations, and the adoption will completely terminate every aspect of the legal relationship which I may have concerning the minor, except for arrearages of child support.

(o) That before executing this consent I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling.

(8) If this consent is being made conditional upon other conditions which are authorized under 15A V.S.A. § 2-406(e), then those conditions are set forth with particularity here. (If none, so state.)

_______________________________________________________________________________

(9) I (circle one) have/have not participated as a party, witness, or in any other capacity in any litigation or action concerning the custody or support of the above-named minor in Vermont or any other state. I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of the child, or who claims to have custody or visitation rights with this child. (Any affirmative answer in this paragraph requires a description of the action or claim, including the court and docket number if available.)

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 _____ day of _______________, _____, at __________, County of ____________________, and State of ____________________.

___________________________________

(signature)

___________________________________

(typed or printed name)

CERTIFICATION

The Consent to Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. § 2-405. Those facts set forth in the consent were sworn to, under oath or affirmation, and I hereby certify that I explained to the person executing the consent the contents and consequences of the consent, and to the best of my knowledge or belief, the person executing the consent:

(a) read this consent, or had it read to them;

(b) signed this consent voluntarily;

(d) was informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee;

(e) if a minor, the minor signing the consent was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ____________________ and he was present as this consent was executed;

(f) if an adult, the person was informed of his or her right to have an attorney represent them in this matter who is not representing the adoptive parent or representing the adoption agency to which the child is being relinquished;

(g) if a mother who has not identified a biological father, then the mother responded to inquiries as provided for under 15A V.S.A. § 3-404;

(h) if a parent is deceased, then the person signing the consent has provided the names and addresses of the persons described in 15A V.S.A. § 3- 401(a)(6);

(i) the person understands that personal counseling was available by a certified adoption counselor, or other counselor, of his or her choice;

(j) I have received a statement from the adoptive parent indicating an intention to adopt as required in 15A V.S.A. § 2-405(e).

(k) The person signing this consent has also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee and the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

Dated this _____ day of _______________, 19_____, at _______________, County of ____________________, and State of ____________________.

_________________________________________________________________

(signature)

_________________________________________________________________

(printed name) of Judge or other person authorized under statute

[Former Form 125A deleted and Temporary Form 125A adopted, effective July 1, 1996. Amended and redesignated effective March 1, 1997; amended July 2, 2004, effective October 1, 2004.]

Vt. R. Prob. P. Form 125B

Vermont Rules of Probate Procedure, Form 125B

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 125B. Relinquishment of Minor to Agency for Adoption

STATE OF VERMONT PROBATE COURT

DISTRICT OF _______________.SS DOCKET NO. _______

IN RE THE ADOPTION OF ____________________, A MINOR OF ____________________

RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION

15A V.S.A. § 2-406

NOW COMES the undersigned person, ____________________, and does swear or affirm under oath to the facts set forth herein and does relinquish a child for adoption as set forth in more detail below:

(1) My full name is _______________; my date of birth is __________; my current mailing address is ______________________________; I am (check one) ( ) married; ( ) single and never married; ( ) single and divorced.

(2a) The full recorded name of the minor being relinquished for adoption is __________ _______________: (circle one) his or her date of birth is _______________ and the time of birth was _____ (A.M./P.M.). The minor is currently living at the following address: ______________________________, and has lived there for _______________ (weeks, months or years). My relationship to the minor being relinquished is: _______________ (parent, legal guardian, etc.) and I have authority to relinquish this minor for adoption.

(2b) The full name and address of the other parent is: ________________________ _______________________________________________________________________________ ______________________________________________________________________________

If full name and address is not provided, please state the reason: __________ _______________________________________________________________________________ ______________________________________________________________________________

(3) The name, address and telephone number of the adoption agency to which the relinquishment is being made is:

Name: ________________________________________________________________________

Address: ______________________________________________________________________ ______________________________________________________________________________

Telephone No. __________________________________________________________________ . ___________________________________________________________________________.

(4) After careful consideration, I believe that it is in the best interests of my said child to be placed for adoption. I am voluntarily and unequivocally consenting to the permanent transfer of legal and physical custody of the above minor to the above adoption agency for the purposes of adoption and to take any and all other measures that may be in the best interests of the minor.

(5) I understand that I may revoke this relinquishment by notifying the court in which this relinquishment was signed, and the above adoption agency, in writing within 21 days after this relinquishment is executed that I wish to revoke this relinquishment. (I understand that if I and the above adoption agency agree, we may jointly revoke this relinquishment anytime before finalization of the adoption. If the adoption agency does not agree to revoke after the 21 day period has expired, then the relinquishment becomes irrevocable on the 22nd day after its execution.) I understand that if this relinquishment is obtained by fraud or duress, or if a condition which would permit revocation had occurred, then I may petition the court to have this relinquishment revoked. A motion to set aside this relinquishment on the basis of fraud, duress, or otherwise, would be filed in the ______________________________ District Probate Court located at ______________________________.

(6) I certify to the following:

(a) I have read this relinquishment, or I have had it read to me;

(b) English is my native language (if not, see 15A V.S.A. § 2-406(a));

(d) I have received a copy of this relinquishment;

(e) Before signing this relinquishment, I have been informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this relinquishment, my signing of this relinquishment and failure to revoke the relinquishment terminates any right I may have to object to the minor's adoption by the adoptive parent(s) as authorized by the agency. I also have been informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee. I have provided accurate information about the identity of the minor's other parent. I understand that when the child reaches the age of majority, he or she will be given information about my identity upon request unless I have signed a request for nondisclosure of identifying information. If I have signed such a request, I understand that I may withdraw it at any time;

(f) If I am a minor, I certify that I was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ______________________________ and he or she is present as this relinquishment is being executed;

(h) I have provided to the agency nonidentifying information and information about the child's and my family's health history and background as required by 15A V.S.A. § 2-105, and I understand that before the adoption becomes final, if information becomes available to me which was unavailable previously, then I have an obligation to provide this information;

(i) I have been made aware that it is in the best interests of the adoptee that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop which could affect the child so that the court or agency may respond to any inquiry concerning the adoptee's medical or social history; I have also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee. I have also been made aware of the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

(j) I have not received or been promised any money, or anything of value, in exchange for my executing this relinquishment except for payments which are authorized under 15A V.S.A. § 7-103 and which are itemized on an attachment to this relinquishment; I (circle one) have/have not been a recipient of public assistance during the last 12 months;

(k) The minor child (circle one) is/is not an Indian Child as defined in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq.

(l) That I (choose one)

( ) waive notice of any proceeding for adoption of the adoptee;

( ) waive notice of the adoption unless the adoption is contested, appealed or denied;

( ) do not waive notice of any proceeding for adoption and I would like to be notified at my address as set forth above;

(m) I understand that the adoption will make any orders or agreements for visitation or communication with the minor unenforceable;

(n) I understand that after this relinquishment has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2- 409, then the relinquishment becomes final and may not be revoked or set aside for any reason, including the failure of the adoptive parent or agency to permit me to visit or communicate with the minor adoptee. I further understand that this relinquishment will extinguish all parental rights and obligations, and the adoption will completely terminate every aspect of the legal relationship which I may have concerning the minor, except for arrearages of child support.

(o) That before executing this relinquishment I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling.

(7) If this relinquishment is being made conditional upon other conditions which are authorized under 15A V.S.A. § 2-406(e), then those conditions are set forth with particularity here. (If none, so state.)

________________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________

(8) I (circle one) have/have not participated as a party, witness, or in any other capacity in any litigation or action concerning the custody or support of the above-named minor in Vermont or any other state. I (circle one) have/have no information concerning any prior custody proceedings (including adoption, guardianship, divorce or paternity actions) concerning the minor which are pending or have been completed. I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of this child. (Any affirmative answer in this paragraph requires a description of the action or claim, including the court and docket number if available.)

I swear that the factual information set forth in this relinquishment is true and correct to the best of my knowledge and belief.

Dated this _____ day of _______________, _____, at _______________, County of ____________________, and State of _______________.

___________________________________

(signature)

___________________________________

(typed or printed name)

CERTIFICATION

The Relinquishment of Minor For Adoption set forth above was signed in my presence, pursuant to 15A V.S.A. § 2-405. Those facts set forth in the relinquishment were sworn to, under oath or affirmation, and I hereby certify that I explained to the person executing the relinquishment the contents and consequences of the relinquishment, and to the best of my knowledge or belief, the person executing the relinquishment:

(a) read this relinquishment, or had it read to them;

(b) signed this relinquishment voluntarily;

(e) if a minor, the minor signing the relinquishment was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ______________________________ and he was present as this relinquishment was executed;

(g) if a mother who has not identified a biological father, then the mother responded to inquiries as provided for under 15A V.S.A. § 3-404;

(h) if a parent is deceased, then the person signing the relinquishment has provided the names and addresses of the persons described in 15A V.S.A. § 3-401(a)(6);

(i) the person understands that personal counseling was available by a certified adoption counselor, or other counselor, of his or her choice;

(j) I have received a statement from the adoption agency indicating an acceptance of the relinquishment as required in 15A V.S.A. § 2-405(f).

(k) The person signing this relinquishment has also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee and the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

Dated this _____ day of _______________, _____, at _______________, County of ____________________, and State of _______________.

_________________________________________________________________

(signature)

_________________________________________________________________

(printed name) of Judge or other person authorized under statute

[Former Form 125B deleted and Temporary Form 125B adopted effective July 1, 1996. Amended and redesignated effective March 1, 1997; amended July 2004, effective October 1, 2004.]

Vt. R. Prob. P. Form 128

Vermont Rules of Probate Procedure, Form 128

Vermont Rules of Court

Rules of Probate Procedure

Appendix of Forms

Trusts

Form 128. Relinquishment of Minor to Agency for Adoption

STATE OF VERMONT PROBATE COURT

DISTRICT OF ____________, SS Docket No. __________

IN RE THE ADOPTION OF __________, A MINOR OF ________________

________________________________________

RELINQUISHMENT OF MINOR TO AGENCY FOR ADOPTION

15A V.S.A. § 2-406

NOW COMES the undersigned person, ____________________, and does swear or affirm under oath to the facts set forth herein and does relinquish a child for adoption as set forth in more detail below:

(1) My full name is ____________________; my date of birth is __________, my current mailing address is ____________________; I am (check one) [ ] married; [ ] single and never married; [ ] single and divorced.

(2a) The full recorded name of the minor being relinquished for adoption is ____________________; (circle one) his or her date of birth is __________ and the time of birth was ___ (A.M./P.M.). The minor is currently living at the following address: ____________________, and has lived there for ___ (weeks, months or years). My relationship to the minor being relinquished is: __________ (parent, legal guardian, etc.) and I have authority to relinquish this minor for adoption.

(2b) The full name and address of the other parent is:

_______________________________________________________________________________

The date of birth of the other parent is __________; the other parent is (check one) [ ] married; [ ] single and never married; [ ] single and divorced.

If the full name and address is not provided, please state the reason:

_______________________________________________________________________________

(3) The name, address and telephone number of the adoption agency to which the relinquishment is being made is:

Name: ________________________________________________________________________

Address: _____________________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________.

Telephone No. ____________________.

(4) After careful consideration, I believe that it is the best interests of my said child to be placed for adoption. I am voluntarily and unequivocally consenting to the permanent transfer of legal and physical custody of the above minor to the above adoption agency for the purposes of adoption and to take any and all other measures that may be in the best interests of the minor.

(6) I certify to the following:

(a) I have read this relinquishment, or I have had it read to me;

(b) English is my native language (if not, see 15A V.S.A. § 2-406(a));

(d) I have received a copy of this relinquishment;

(e) Before signing this relinquishment, I have been informed of the meaning and consequences of adoption. I understand that, unless otherwise provided in this relinquishment, my signing of this relinquishment and failure to revoke the relinquishment terminates any right I may have to object to the minor's adoption by the adoptive parent(s) as authorized by the agency. I also have been informed about the consequences of misidentifying the other parent of this child and the procedure for releasing information about health, characteristics, and identity of myself to the adoptee. I have provided accurate information about the identity of the minor's other parent. I understand that when the child reaches the age of majority, he or she will be given information about my identity upon request unless I have signed a request for non-disclosure of identifying information. If I have signed such a request, I understand that I may withdraw it at any time;

(f) If I am a minor, I certify that I was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ____________________ and he or she is present as this relinquishment is being executed;

(h) I have provided to the agency nonidentifying information and information about the child's and my family's health history and background as required by 15A V.S.A. § 2-105, and I understand that before adoption becomes final, if information becomes available to me which was unavailable previously, then I have an obligation to provide this information;

(i) I have been made aware that it is in the best interest of the adoptee that I keep the court or the adoption agency informed of my current address and any family health problems of mine which may develop which could affect the child so that the court or agency may respond to any inquiry concerning the adoptee's medical or social history; I have also been made aware of the procedure for releasing information about the health and other characteristics of the parent which may affect the physical or psychological well-being of the adoptee. I have been made aware of the procedure for release of the parent's identity pursuant to Article 6 of the Vermont Adoption Act.

(k) The minor child (circle one) is/is not an Indian Child as defined in the Indian Child Welfare Act, 25 U.S.C. § 1901 et seq.

(l) That I (choose one)

[ ] waive notice of any proceeding for adoption of the adoptee;

[ ] waive notice of the adoption unless the adoption is contested, appealed or denied;

[ ] do not waive notice of any proceeding for adoption and I would like to be notified at my address as set forth above;

(m) I understand that the adoption will make any orders or agreements for visitation or communication with the minor unenforceable;

(n) I understand that after this relinquishment has been executed in compliance with § 2-405 and not revoked in compliance with § 2-408 or § 2-409, then the relinquishment becomes final and may not be revoked or set aside for any reason, including the failure of the adoptive parent or agency to permit me to visit or communicate with the minor adoptee. I further understand that this relinquishment will extinguish all parental rights and obligations, and the adoption will completely terminate every aspect of the legal relationship which I may have concerning the minor, except for arrearages of child support.

(o) That before executing this relinquishment I was informed of the availability of personal counseling by a certified adoption counselor, or other counselor of my choice and legal counseling.

_______________________________________________________________________________

(8) I (circle one) have/have not participated as a party, witness, or in any other capacity in any litigation or action concerning the custody or support of the above-named minor in Vermont or any other state. I (circle one) have/have no information concerning any prior custody proceeding (including adoption, guardianship, divorce or paternity actions) concerning the minor which are pending or have been completed. I (circle one) have/have no knowledge of any person or adoption agency or state agency who has physical or legal custody of this child. (Any affirmative answer in this paragraph requires a description of the action or claim, including the court and docket number if available.)

I swear that the factual information set forth in this relinquishment is true and correct to the best of my knowledge and belief.

Dated this ___ day of __________, ___, at __________, County of __________, and State of __________.

________________________________________

(signature)

________________________________________

(typed or printed name)

CERTIFICATION

(a) read this relinquishment, or had it read to them;

(b) signed this relinquishment voluntarily;

(e) if a minor, the minor signing the relinquishment was advised by an attorney who is not representing the adoptive parent or the adoption agency to which the child is being relinquished; the name of the attorney is ____________________ and he was present as this relinquishment was executed;

(f) if an adult, the person was informed of his or her right to have an attorney represent them in this matter who is not representing the adoptive par