STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CERTIFICATE OF COUNSELING 18-A M.R.S. � 9-202(b)(1) 1. I, _________________________________________, am A caseworker/counselor with the Maine Department of Health and Human Services and qualified to counsel parents to consent to an adoption of their child, OR A caseworker/counselor with ______________________________________, a duly licensed child-placing agency in Maine and qualified to counsel parents desiring to consent to an adoption of their child. 2. In accordance with 18-A M.R.S. � 9-202(b)(1) I hereby certify that (insert name here) _________________________________________________has received counseling regarding: This parent's consent to the above captioned adoption; OR This parent's surrender and release of the above named child to (insert name here) _____________________________________ for the purpose of adoption; OR (insert name here)__________________________________________ has refused to accept counseling regarding this parent's consent or surrender and release. Dated: Signature Name and Title of Counselor AD-012, Rev. 10/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MAINE , ss. Personally appeared the above named , who under penalty of perjury, affirmed that the foregoing statements are true and who acknowledged this instrument to be his/her free act and deed and the free act and deed of the organization he/she represents. Dated: Notary Public Date Commission Expires AD-012, Rev. 10/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com