Fill and Sign the Termination of Parental Rights New Hampshire Judicial Branch Form

NHJB-2233-DF (07/01/2011) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Number: IN THE MATTER OF: DOB: RIGHT TO AN ATTORNEY IN A TERMINATION OF PARENTAL RIGHTS CASE REQUEST FOR COURT-APPO INTED ATTORNEY OR WAIVER OF RIGH T TO AN ATTORNEY I, , of , Name Address being the of , a minor Relationship Child's Name(s) child, have been notified to appear befor e the court to answer to a petition to terminate my parental rights pursuant to the RSA 170-C. I have been advised of my right to be represented by an attorney at every point in the case and at every court hearing. I have been advised that if I do not think that I can afford to pay an attorney that I may apply to the court for a court-appointed attor ney to represent my interests. To apply for a court-appointed attorney, I understand that I must complete a Financial Affidavit & Application for Court Appointed Counsel (NHJB 2313-DSSup) form and this Right to an Attorney form and submit both to the court listed on the fr ont of the petition. If I financially qualify to have an attorney represent me, I understand that the c ourt will appoint one. If an attorney is appointed to represent me, I understand that I may be asked to pay back some or all of the court-appointed attor ney's fees. This will be based upo n my ability to pay as determined by the court. I understand that the processing of this ca se involves important legal, procedural and constitutional matters, including th e examination of witnesses, offering of testimony and presentation of evidence. I further understand t hat if the court orders that my parental rights be terminated, I will no longer have any legal rights, privileges, duties or obligations regarding my child including, but not limited to, rights to custody, visitation and communi cation with my child. I understand that if my parental rights are terminated, I wil l receive no notice of any future legal proceedings concerning my child. Case Number: RIGHT TO ATTORNEY – TPR NHJB-2233-DF (07/01/2011) Page 2 of 2 Please check one (1) of the three (3) boxes below and sign and date the form. 1. I will hire an attorney to represent me. 2. I do not think that I can affo rd to hire an attorney and woul d like to apply for a court- appointed attorney. My completed Financial Affidavit & Application for Court Appointed Counsel form is enclosed. Date Signature of Parent Printed Name of Parent WAIVER OF RIGHT TO AN ATTORNEY 3. I do not want an attorney to represent me an d waive my right at this time to hire an attorney or apply for a court-appointed attorney. I have read and understand each of the statements below and have initialed each statement indicating I understand: I am giving up my right to hav e an attorney assist me with the processing of this case which involves important legal, procedural and constitutional matters, including the examination of witnesses, offering of testimony and presentation of evidence. If at the end of the case t he court orders that my parental ri ghts be terminated, I will no longer have any legal rights, privileges, dut ies or obligations regarding my child including, but not limited to, rights to custody, vi sitation and communication with my child . I understand that if my parental rights are terminated, I will receive no notice of any future legal proceedings concerning my child. Date Signature of Parent Printed Name of Parent The above named parent has waived her/his right to an attorney. I have reviewed the content of this fo rm with the parent and have determined that s/he understands the right to either hire an attorney or apply to have a court-appointed attorney represent her/him. I have det ermined s/he understands the rights s/he is giving up by waiving counsel and understands the consequences of a cour t order terminating her/his parental rights. So Ordered: Date Signature of Judge Printed Name of Judge