STATE OF MAINE DISTRICT COURT Location: Docket No.: Petitioner Petitioner UNCONTESTED JOINT PETITION FOR PRE- BIRTH DETERMINATION OF PARENTAGE 19-A M.R.S. �� 1921-1938, 1652, 1653, 1851 v. Respondent Respondent's Spouse (if married) Now come the Petitioner(s) jointly with Respondent(s) and commence this action to determine parentage and parental rights and responsibilities of a minor child(ren) pursuant to the Maine Parentage Act, 19-A M.R.S.�� 1931-1938, and states as follows: 1. Petitioner(s) is the intended parent(s) of a child(ren) due to be born on ______________________. 2. Respondent is the gestational carrier of the minor child(ren). 3. Respondent is married and her spouse OR Respondent is not married. , (county) , (county) is joined as a party in this proceeding. 4. Petitioner(s) reside(s) in (town) 5. Respondent(s) reside(s) in (town) , (state) , (state) . . 6. Maine has jurisdiction in this case because all parties to the Petition agree to submit to the jurisdiction of this State, and at least one of the parties resides in this State. 7. Petitioner(s) and Respondent(s) entered into a written gestational carrier agreement in compliance with 19-A M.R.S. �1932. 8. Pursuant to the gestational carrier agreement, Respondent agreed to pregnancy by means of assisted reproduction and she (and her spouse if she is married) agreed to have no rights and duties as the parent(s) of the child(ren) conceived through assisted reproduction. FM-216, Rev. 08/16 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 9. Petitioner(s) agreed to be the exclusive parent(s) of any resulting child(ren) and agreed to accept all parental rights and responsibilities of any resulting child(ren) immediately upon the birth of the child(ren). 10. Petitioners(s) and Respondent(s) declare that their gestational carrier agreement fully complies with all of the following statutory requirements. A. B. C. D. E. F. G. The gestational carrier agreement is in writing and has been signed by all parties. The agreement requires no more than a one-year term to achieve pregnancy. At least one of the parties to the agreement is a legal resident of this State. The agreement was executed before the transfer of any embryos. The gestational carrier is 21 years old or older. The gestational carrier has previously given birth to at least one child. The gestational carrier did not contribute gametes for use in her pregnancy. OR The gestational carrier did contribute gametes for use in her pregnancy, but has entered into a gestational carrier agreement with a family member. The agreement provides that the gestational carrier has the right to use the services of a health care provider of her choosing to provide her care during pregnancy. The gestational carrier has completed a medical evaluation that includes a mental health evaluation, and has provided records related to the evaluation to the intended parent(s). The intended parent(s) has completed a medical evaluation that includes a mental health evaluation, and has provided records related to the evaluation to the gestational carrier. The gestational carrier has had independent legal representation of her own choosing and paid for by the intended parent(s) in all matters concerning the terms of the gestational carrier agreement, and has been advised of the legal consequences of the gestational carrier agreement. The attorney representing the gestational carrier has completed a declaration that is attached to the gestational carrier agreement stating that the agreement meets all of the requirements of the Maine Parentage Act. The intended parent(s) has had independent legal representation in all matters concerning the terms of the gestational carrier agreement. The attorney representing the intended parent(s) has completed a declaration that is attached to the gestational carrier agreement stating that the agreement meets all of the requirements of the Maine Parentage Act. The agreement expressly provides that the gestational carrier must undergo assisted reproduction and attempt to give birth to any resulting child(ren). Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com H. I. J. K. L. M. N. O. FM-216, Rev. 08/16 P. The agreement expressly provides that the gestational carrier has no claim to parentage of any resulting child(ren), and the gestational carrier acknowledges the exclusive parentage of the intended parent(s) of all resulting child(ren) immediately upon the birth of the child(ren). The gestational carrier is married. The gestational carrier agreement is signed by the gestational carrier's spouse, the spouse agrees to abide by the obligations imposed on the gestational carrier by the terms of the gestational carrier agreement, the spouse acknowledges to have no claim to parentage of any resulting child(ren), and acknowledges the exclusive parentage of the intended parent(s) of all resulting child(ren) immediately upon the birth of the child(ren). OR The gestational carrier is not married. The agreement provides that the intended parent(s) are the exclusive parent(s) of all resulting children immediately upon the birth of the child(ren) regardless of whether a court order has been issued at the time of birth, that the intended parents accept all parental rights and responsibilities of all resulting child(ren) immediately upon birth regardless of the number, gender, or mental or physical condition of the child(ren), and that the intended parent(s) assume responsibility for the financial support of all resulting child(ren) immediately upon the birth of the child(ren). The gestational carrier has signed a written acknowledgment that she has received a copy of the gestational carrier agreement. Q. R. S. Wherefore, pursuant to 19-A M.R.S. � 1934, Petitioner(s) and Respondent(s) jointly request an order: Designating the contents of the birth certificate(s) in accordance with Title 22, section 2761 and directing the Office of Data, Research and Vital Statistics to designate the intended parent(s) as the parent(s) of the child(ren); Declaring that the intended parent(s) are the parent(s) of the resulting child(ren), and ordering that all parental rights and responsibilities vest exclusively in the intended parent(s) immediately upon the birth of the child(ren); Sealing the record from the public to protect the privacy of the child(ren) and the parties; Any further relief that the court determines necessary and proper. Date: (Petitioner's signature) Attorney