Fill and Sign the Purpose to Describe the Requirements Related to Vermont Dcf Form

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 1 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 MY LEGAL RELATIONSHIP WITH MY CHILD 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 700-00135A – Statement of Putative Father & Waiver of Counsel (06/2019) Page 2 of 2