Fillable Form 700 00138.2 (Vermont Judiciary)

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Form 700 00138.2 (Vermont Judiciary)

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700-00138 – Statement of Payments to Agency of Attorney in Connection with Adoption (03/2017) Page 1 of 1
STATEMENT OF PAYMENTS TO AGENCY OR ATTORNEY IN CONNECTION WITH ADOPTION
STATE OF VERMONT PROBATE COURT
DISTRICT OF
IN RE ADOPTION OF:
DOCKET NO:
Payments to Agency or Attorney in
Connection with Adoption 15A V.S.A. § 3-
702
0
Agency
0
Attorney
Organization:
Child’s name:
Birthmother’s name (if known):
Address:
Birthfather’s name (if known):
Telephone #:
Date
Names of Persons Who Have Paid Fees:
Persons Who Have Agreed to Pay Fees:
Purpose of Payment
TOTALS
I swear and affirm that the expenses listed above are the only payments or compensation made or agreed to be made to this agency or attorney in connection with
the adoption of the child listed above.
Signed: _____________________________ Agency or Law Firm: _________________________________ Date: _____________________
Sworn before me on ___________________ in ________________________ in the County of ___________________, State of ___________________________
Notary Public: ___________________________________________________ My commission expires on ______________________
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Form 700 00138.2 (Vermont Judiciary)

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Completed 15 July 2020

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