Vermont > Statewide > Probate Court
Statement Of Putative Father And Waiver Of Counsel 135A - Vermont
| Statement Of Putative Father And Waiver Of Counsel Form. This is a Vermont form and can be used in Probate Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Probate Court Form No. 135A Statement of Putative Father & Waiver of Counsel ( Page 1of 2 ) STATE OF VERMONT PROBATE COURT DISTRICT OF _______________________DOC KET NO. _____________IN RE: ADOPTION OF __________________ STATEMENT OF PUTATIVE FATHER Pursuant to 15A V. S. A. 2-402 (a)(3) and WAIVER OF COUNSEL Pursuant to 15A V. S. A. 3-503 (a)(1) I, _________________________________, of ________________________________ __, Name City and State hereby acknowledge that I have been named as the biological father of _____________________________________,born _________________________________ Childs Name Date in ___________________________________, I hereby give notice to all interested parties as follows: City and State (Please check one ) ________ I deny that I am the biologcal father of this child and hai ve no further interest in any pending or proposed adoption proceedings concerning this child. ________ I admit that I am the biological father of this child, but I disclaim any interest in this child and waive further notice of anypending or proposed adoption proceedings concerning this child ________ I admit that I am the biological father of this child and object to any pending or proposed adoption. I wish to receive notice of all further adoption proceedings concerning this child. I will _____ I will not _____ (please check one) provide birth parent information to the court. Thisinformation may be provided to the child wen he or she attains the agh e of majority. I hereby acknowledge that this notice is irrevcable and mo ay be admitted into evidence in anyadoption proceeding concerning __________________________. Minor Childs Name I understand that I am entitled to be represented an attorneyby who is not representing an adoptiveparent or an agency to which the parents child is being relinquished. I understand that these proceedings may result in the TERMINATION OF MY RELATIONSHIPTO MY CHILD. I understand that an attorney will be appointed present mto re e if I want an attorney and cannot affordto hire an attorney at my own expense. <<<<<<<<<********>>>>>>>>>>>>> 2Probate Court Form No. 135A Statement of Putative Father & Waiver of Counsel ( Page 2 of 2 ) I DO NOT WISH TO BE REPRESENTED BY AN ATTORNEY, and I hereby waive my right tobe represented by an attorney in these proceedings. Please send all correspondence to me at the address below: ________________________________________ Signature ________________________________________ Print Name ________________________________________ Street Name and Number _______________________________________ City, State and Zip Code _______________________________________ Telephone Number (Home) (Work) Signed in the presence of Notary Public or other person authorized by the Probate Court. Subscribed and sworn to this _____ day of _______________ 20_____, Before me, ___________________________________ Notary Public
|
|||||||
