THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Number: IN THE MATTER OF: IN THE MATTER OF: IN THE MATTER OF: IN THE MATTER OF: DOB: DOB: DOB: DOB: I, Name RIGHT TO AN ATTORNEY IN AN ABUSE OR NEGLECT CASE REQUEST FOR COURT-APPOINTED ATTORNEY OR WAIVER OF RIGHT TO AN ATTORNEY , of Address , , a minor being the Relationship of Child(ren)'s Name(s) child(ren), have been notified to appear before the court to answer to a petition alleging that my child(ren) have been abused and/or neglected pursuant to the New Hampshire Child Protection Act (RSA 169-C). I have been advised of my right to be represented by an attorney at every point in the case and at every court hearing. I have been advised that if I do not think that I can afford to pay an attorney that I may apply to the court for a court-appointed attorney to represent my interests. To apply for a court-appointed attorney, I understand that I must complete a Financial Affidavit form and this Right to an Attorney form and submit both to the court listed on the front of the petition for review. If I financially qualify to have an attorney represent me, I understand that the court will appoint one. If an attorney is appointed to represent me, I understand that I may be asked to pay back some or all of the court-appointed attorney's fees. This will be based upon my ability to pay as determined by the court. I understand that the processing of this case involves important legal, procedural and constitutional matters, including the examination of witnesses, offering of testimony and presentation of evidence. I further understand that if the court makes a finding of "TRUE" that my child(ren) have been abused and/or neglected, the finding may be the basis at a future time for a petition to terminate my parental rights. If my parental rights are terminated, I understand that I will no longer have any legal rights, privileges, duties or obligations regarding the child(ren). I understand that even if I waive my right at this time to hire an attorney or to apply for a courtappointed attorney, I may at any time during the course of this case exercise my right to either hire an attorney or apply for a court-appointed one. NHJB-2825-DF (07/01/2013) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: RIGHT TO ATTORNEY ­ ABUSE & NEGLECT Please check one (1) of the three (3) boxes below and sign and date the form. 1. 2. I will hire an attorney to represent me. I do not think that I can afford to hire an attorney and would like to apply for a courtappointed attorney. My completed Financial Affidavit form is enclosed. Date Signature of Parent Printed Name of Parent WAIVER OF RIGHT TO AN ATTORNEY 3. I do not want an attorney to represent me and waive my right at this time to hire an attorney or apply for a court-appointed attorney. By signing below, I understand that even though I have waived my right at this time to have an attorney represent me, I understand that I may at any time during the course of this case exercise my right to either hire an attorney or apply for a court-appointed attorney. Date Signature of Parent Printed Name of Parent The above named parent has waived her/his right to an attorney. I have reviewed the content of this form with the parent and have determined that s/he understands the right to either hire an attorney or apply to have a court-appointed attorney represent her/him. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge NHJB-2825-DF (07/01/2013) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com