Fill and Sign the Vt Father 497428863 Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) STATEMENT OF PUTATIVE FATHER Pursuant to 15A VSA 2-402(a)(3) and WAIVER OF COUNSEL Pursuant to 15A VSA 3-503(A)(1) I, Name , of City , ST hereby acknowledge that I have been named as the biological father of Child's Name , born ______________________ , in City , ST I hereby give notice to all interested parties as follows: Please 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 notice of a 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 provide birth parent information to the court. This information may be provided to the child when he or she - 1 - attains that age of majority. I hereby acknowledge that this notice is irrevocable 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 any 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 represent me if I want an attorney and cannot afford to hire an attorney at my own expense. I DO NOT WISH TO BE REPRESENTED BY AN ATTORNEY, 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 address) ________________________________________________ (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, - 2 - _________________________________________________ Notary Public Commission Expires: _________________________ Rev. 3/2/98 - 3 -