Statement Of Payments To Agency Of Attorney In Connection With Adoption {138}

700 - 00138 Statement of Payments to Agency of Attorney in Connection with Adoption (03/2017) Page 1 of 1 STATEMENT OF PAYMENTS TO AGENCY O ATTORNEY IN CONNECTION WITH ADOPTION S T A T E O F VERM O N T PR O BA T E C O URT DIS T RIC T O F I N R E AD O P T I O N O F : D O CKE T N O : Pa y ment s t o A g enc y o r A tt o r n ey in Connect i o n w i t h A dopt i o n 15A V.S. A . 247 3 - 702 0 Agen c y 0 Attorney O r gan i z at i on: C h il d s na m e: B ir th m othe r s na m e (i f known ) : Add r ess: B ir thfathe r s na m e (i f known ) : Te l ephone #: Da te Name s of Pers ons W ho Ha v e Pai d F ees: Pers ons W ho Ha v e A g ree d to Pa y F ees: P u r po s e of Pa y m e nt T O T A LS I s w ea r an d a ff i rm tha t th e e x pen s e s li s te d abov e a re th e onl y pa y m ent s o r c o m pen s atio n m ad e o r ag r ee d t o b e m ad e t o thi s agenc y o r atto r ne y i n c onne c tio n w i th th e adoptio n o f th e c hil d li s te d above. Signed: Agency or Law Firm: Date: Sworn before me on in in the County of , State of Notary Public: My commission expires on American LegalNet, Inc. www.FormsWorkFlow.com