Fill and Sign the Waiver of Counsel Vermont Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) WAIVER OF COUNSEL 15A V.S.A. § 3-503(b)(1) I, _________________________________________ , have been informed 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 fully understand that these proceedings may result in the TERMINATION OF MY RELATIONSHIP TO MY CHILD. I fully understand my RIGHT TO AN ATTORNEY, and it has been explained to me 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. However, 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. Date: ___________ Signed: ______________________ ,Petitioner Print Name: ______________________________ Address: ________________________________________ Telephone: (       ) _______________ Signed in the presence of a Notary Public or other person authorized by the Probate Court. Subscribed and sworn to this ________ day of ____________ , _____________ , before me. __________________________________________________________ Notary Public Commission expires: _______________________________________ Print name: _______________________________________________ Address: ____________________________________________________________ _ ____________________________________________________________ _ ____________________________________________________________ _ Telephone No.: ( ) ____________________________________________________________ _ Rev.3/1/97