Fill and Sign the Voluntarily Mediated Agreement Form

NHJB-2302-FP (05/01/2018) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) VOLUNTARILY MEDIATED AGREEMENT 1. This agreement is entered into pursuant to the provisions of RSA 170-B:14, II. 2. Any breach, modification, or invalidation of this agreement, or any part of it, shall not affect the validity of the surrender of parent al rights or the interlocutory or final decree of adoption. 3. The parties acknowledge that both the birt h and prospective adoptive parents who have entered into the agreement have the right to seek enforc ement as set forth in RSA-170-B:14, II(i). 4. The parties have not relied on an y representations other than those contained in this agreement. 5. This agreement was entered in to knowingly and voluntarily and is not the product of coercion, fraud, or duress. Case Name: Case Number: VOLUNTARILY MEDIATED AGREEMENT NHJB-2302-FP (05/01/2018) Page 2 of 2 This agreement is signed as my free act and deed. Date Birth Parent (Father/Mothe r) Birth Parent (Father/Mother) Date Attorney for Birth Parent Attorney for Birth Parent Date Adoptive Parent (Father/Mot her) Adoptive Parent (Father/Mother) Date Attorney for Adoptive Parent Attorney for Adoptive Parent Date Div. for Children, Youth & Families CHILD'S ASSENT I am the child mentioned in this agreement, I am 14 years of age or older , and I give my assent to this voluntarily medi ated agreement. D ate C hild S ig na tu re State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER This agreement is approved. Date Signature of Judge Name of Judge