Fill and Sign the Probate Court Form 135

Probate Court Form 135 Waiver of Counsel STATE OF VERMONT PROBATE COURT DIS T R ICT OF _______________________ DOCKET NO. ___________________ IN RE THE ADOPTION OF __________________________ WAIVER OF COUNSEL15A V. S. A. 3 -503(b)(1) I, ____________ ________________________, have been informed that I am entitled to be represented by an attorney who is not representing an adoptive parent or an agency to which the parent’s child is being relinquished. I fully understand that these proceedings may result in the TERMINATION OF MY RELATIONSHIP TO MY CHILD. I fully understand my RIGHT TO AN ATTORNEY, and it has been explained to me that an attorney will be appointed to represent me if I want an attorney and cannot afford to hire an attorney at my own expense. 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 proceedings. Please send all correspondence to me at the address below. Signature : ________________________________ Date: ________________________________ Address: ________________________________ ________________________________________________________________ Telephone: Home ( ) _______________________ Work ( ) _______________ Signed in the presence of a Notary Public or other person authorized by the Probate Court. Subscribed and sworn to on this ____________________ day of ___________________, 20_____. Before me, _______________________________________ Notary Public, Judge