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700-00135 – Waiver of Counsel (06/2019) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of :
WAIVER OF COUNSEL
15A V.S A. 3 -503(b)(1)
I have been informed that I am entitled to be represented by an attorney who does not represent an adoptive
parent or an agency to which my child is being relinquished.
I fully understand that these proceedings may result in the
TERMINATION
OF
M
Y LEGAL
RELATIONSHIP
TO
MY
CH
I
L
D AND ALL MY PARENTAL RIGHTS AND RESPONSIBILITIES.
I fully understand my RIGHT TO AN ATTORNEY. I understand that if I want an attorney and cannot afford to
hire an attorney at my own expense, an attorney will be appointed to represent me at no cost to me.
However, I DO NOT WISH TO BE
REPRESENTED
BY AN ATTORNEY, and I hereby waive my right to be
represented by an attorney in this proceeding.
Please send all correspondence to me at the address below.
Dated
Signature of Parent
Parent’s Name Printed
Mailing Address
Town/City
State
Phone Number
Subscribed and sworn before me on:
My commission expires on:
Signature of Notary Public or Person Authorized by Probate Court
Printed Name
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Completed 3 July 2020

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