THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) VOLUNTARILY MEDIATED AGREEMENT (RSA 170-B:14) 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 parental rights or the interlocutory or final decree of adoption. 3. The parties acknowledge that both the birth and prospective adoptive parents who have entered into the agreement have the right to seek enforcement as set forth in RSA-170-B:14, II(i). 4. The parties have not relied on any representations other than those contained in this agreement. 5. This agreement was entered into knowingly and voluntarily and is not the product of coercion, fraud, or duress. NHJB-2302-FP (10/01/06) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: VOLUNTARILY MEDIATED AGREEMENT This agreement is signed as my free act and deed. Date Birth Mother Birth Father Date Attorney for Birth Mother Attorney for Birth Father Date Adoptive Mother Adoptive Father Date Attorney for Adoptive Mother Attorney for Adoptive Father Date Div. for Children, Youth & Families State of , County of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any by Signature of Notarial Officer / Title 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 mediated agreement. Date Child Signature This agreement is approved. Date NHJB-2302-FP (10/01/06) Judge signature Printed name Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com