Statement Of Disclosure Of Identifying Information {700-00127}

700 - 00127 Disclosure of Identifying Information (07/2016) Page 1 of 1 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of : STATEMENT OF DISCLOSURE OF IDENTIFYING INFORMATION I m a ke the following state m ent regarding the release of informa tion to the child named below: ( check one box only ) I consent to the release to m y child of my identifying infor m ation including m y na m e and address , should my child request that infor m ation after the age of 18 or e m ancipation. I request that m y na m e and address be kept confidential. I understand that a judge m a y decide to release this infor m ation for very i m portant reasons (i.e., m e dical reasons) even though I have requested confidentiality. I understand that I m a y change m y m i nd about the choice I have made at any ti m e prior to the release of identifying infor m ation by contacting the Adoption Registry, 103 South Main Street, W a terbury, VT 05671 - 2401. Information about Child : Child ' s Full Na m e: Date of Birth: Time of Birth: Place of Birth (town, state, country) : Information:Full Name: Date of Birth: Time of Birth: Place of Birth (town, state, country) : Social Security #: Mailing Address: 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: Date At: Signature of Parent City, County and State Printed Name Signed and sworn to before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com