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700-00135A 0 H:\Probateforms\Forms\Form No. 135 - Waiver of Counsel.wpd

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700-00135A – Statement of Putative Father & Waiver of Counsel (06/2019) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Adoption of :
STATEMENTOF PUTATIVE FATHER AND WAIVER OF COUNSEL
15A V.S A. 2-402(a)(3) and 3 -503(b)(1)
1. My information
My Name
DOB
2. I understand that I have been named the biological father of:
Minor’s Full Name
Minor’s DOB
3. The woman who gave birth to the minor and I have never been married: ☐ Yes ☐ No
4. My Position Regarding Paternity and Notice of Further Adoption Proceedings
I hereby give notice to all interested parties that: check one
☐ I deny that I am the biological father of this child and have 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 any pending 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.
5. Birth Parent Information
Birth parent information may be provided to the minor when he or she attains the age of majority or
emancipation. check one
☐ I will provide birth parent information to the Court.
☐ I will not provide information to the Court.
6. Identifying Information check one
☐ I consent to the release of my name and address should the minor request that information when he or she
attains the age of majority.
☐ I request that my name and address be kept confidential. I understand that a judge may release this
information for very important reasons (e.g. medical reasons) even though I have requested that it remain
confidential.
700-00135A – Statement of Putative Father & Waiver of Counsel (06/2019) Page 2 of 2
7. Notice
☐ I hereby acknowledge that this notice cannot be revoked and may be admitted into evidence in an adoption
proceeding concerning the minor.
8. Waiver of Attorney Representation check all that apply
☐ 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
WITH
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.
☐ 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
Zip
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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700-00135A 0 H:ProbateformsFormsForm No. 135 - Waiver of Counsel.wpd

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Completed 3 July 2020

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