Form 700-00127 "Statement of Disclosure of Identifying Information" - Vermont

What Is Form 700-00127?

This is a legal form that was released by the Vermont Superior Court - a government authority operating within Vermont. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Vermont Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form 700-00127 by clicking the link below or browse more documents and templates provided by the Vermont Superior Court.

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Download Form 700-00127 "Statement of Disclosure of Identifying Information" - Vermont

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STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of:
STATEMENT OF DISCLOSURE OF IDENTIFYING INFORMATION
I make the following statement regarding the release of information to the child named below:
(check one box only)
 I consent to the release to my child of my identifying information including my name and address,
should my child request that information after the age of 18 or emancipation.
 I request that my name and address be kept confidential. I understand that a judge may decide to
release this information for very important reasons (including, but not limited to medical reasons)
even though I have requested confidentiality.
I understand that I may change my mind about the choice I have made at any time prior to the release of
identifying information by contacting the Adoption Registry, 103 South Main Street, Waterbury, VT 05671-
2401.
Information about Child:
Child's Full Name:
______________________________________________________________________
Date of Birth:
_____________________________ Time of Birth: ____________________________
Place of Birth
: _____________________________________________________________
(town, state, country)
My Information:
Full Name:
______________________________________________________________________
Date of Birth:
_____________________________ Time of Birth: ____________________________
Place of Birth
: _____________________________________________________________
(town, state, country)
Driver’s License #:
_____________________________ 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
Signature of Parent
At:
City, County and State
Printed Name
Signed and sworn to before me:
Date
Signature of Notary Public
Expiration Date
700-00127 – Disclosure of Identifying Information (04/2018)
Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of:
STATEMENT OF DISCLOSURE OF IDENTIFYING INFORMATION
I make the following statement regarding the release of information to the child named below:
(check one box only)
 I consent to the release to my child of my identifying information including my name and address,
should my child request that information after the age of 18 or emancipation.
 I request that my name and address be kept confidential. I understand that a judge may decide to
release this information for very important reasons (including, but not limited to medical reasons)
even though I have requested confidentiality.
I understand that I may change my mind about the choice I have made at any time prior to the release of
identifying information by contacting the Adoption Registry, 103 South Main Street, Waterbury, VT 05671-
2401.
Information about Child:
Child's Full Name:
______________________________________________________________________
Date of Birth:
_____________________________ Time of Birth: ____________________________
Place of Birth
: _____________________________________________________________
(town, state, country)
My Information:
Full Name:
______________________________________________________________________
Date of Birth:
_____________________________ Time of Birth: ____________________________
Place of Birth
: _____________________________________________________________
(town, state, country)
Driver’s License #:
_____________________________ 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
Signature of Parent
At:
City, County and State
Printed Name
Signed and sworn to before me:
Date
Signature of Notary Public
Expiration Date
700-00127 – Disclosure of Identifying Information (04/2018)
Page 1 of 1