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Fill and Sign the B Other Statutory Exclusions Archives the Reporters Form

Fill and Sign the B Other Statutory Exclusions Archives the Reporters Form

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FORM 137. S TATEMENT OF ADOPTIVE PARENT EXPENSES STATE OF VERMONT PROBATE COURT DISTRICT OF _________________________ DOCKET NO: ______________ IN RE ADOPTION OF:___________________________________ Adoptive Parent Expenses 15A V.S.A. § 3-702 Child’s Name: Name(s): Address: Birthparents’ Names (if known): Telephone #: Date Name of Recipient Address of Recipient Purpose of Payment TOTALS I/we swear and affirm that the expenses listed above are the onl y disbursements we have made in connection with the adoption of the child listed above. Signed: Adoptive Parent Date Signed: Adoptive Parent Date Sworn before me on ____________________ in ___________________ in the County of , State of __________________________. My commission expires on: Notary Public

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