Fill and Sign the Statement of Putative Father Amp Form

Probate Court Form No. 135A Statement of Putative Father & Waiver of Counsel ( Page 1of 2 ) STATE OF VERMONT PROBATE COURT DIS T R ICT OF _______________________ DOCKET NO. _____________ IN RE: ADOP TION OF __________________ STATEMENT OF PUTATIVE FATHER Pursuant to 15A V. S. A. 2-402 (a)(3) and WAIVER OF COUNSEL Pursuant to 15A V. S. A. 3-503 (a)(1) I, _________________________________, of __________________________________, Name City and State hereby acknowledge that I have been named as the biological father of _____________________________________, born _________________________________ Child’s Name Date in ___________________________________, I hereby give no tice to all interested parties as follows: City and State (Please check one ) ________ I deny that I am the biologi cal father of this child and have no further interest in any pending or proposed adoption pro ceedings 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. I will _____ I will not _____ (please check one) provide bi rth parent information to the court. This information may be provided to the child wh en he or she attains the age of majority. I hereby acknowledge that this notice is irrevo cable and may be admitted into evidence in any adoption proceeding concerning __________________________. Minor Child’s Name I understand 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 understand that these proceedings may result in the TERMINATION OF MY RELATIONSHIP TO MY CHILD. I understand that an attorney will be appointed to re present me if I want an attorney and cannot afford to hire an attorney at my own expense. Probate Court Form No. 135A Statement of Putative Father & Waiver of Counsel ( Page 2 of 2 )I DO NOT WISH TO BE REPRESENTED BY AN A TTORNEY, and I hereby waive my right to be represented by an attorney in these proceedings. Please send all correspondence to me at the address below: ________________________________________ Signature ________________________________________ Print Name ________________________________________ Street Name and Number _______________________________________ City, State and Zip Code _______________________________________ Telephone Number (Home) (Work) Signed in the presence of Notary Public or other person authorized by the Probate Court. Subscribed and sworn to this _____ day of _______________ 20_____, Before me, ___________________________________ Notary Public