700-00135A Statement of Putative Father & Waiver of Counsel () Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of : STATEMENTOF PUTATIVE FATHER AND WAIVER OF COUNSEL 15A V.S A. 2-402(a)(3) and 3 -503(b)(1) 1.My information My Name DOB 2.I understand that I have been named the biological father of: 3.The woman who gave birth to the minor and I have never been married:Yes No 4.My Position Regarding Paternity and Notice of Further Adoption Proceedings I hereby give notice to all interested parties that: check one I deny that I am the biological father of this child and have no further interest in any pending or proposedadoption proceedings concerning this child.I admit that I am the biological father of this child, but I disclaim any interest in this child and waive furthernotice of any pending or proposed adoption proceedings concerning this child.I admit that I am the biological father of this child and object to any pending or proposed adoption. I wish toreceive notice of all further adoption proceedings concerning this child. 5.Birth Parent Information Birth parent information may be provided to the minor when he or she attains the age of majority oremancipation. check one I will provide birth parent information to the Court.I will not provide information to the Court. 6.Identifying Information check one I consent to the release of my name and address should the minor request that information when he or sheattains the age of majority.I request that my name and address be kept confidential. I understand that a judge may release thisinformation for very important reasons (e.g. medical reasons) even though I have requested that it remainconfidential. American LegalNet, Inc. www.FormsWorkFlow.com 700-00135A Statement of Putative Father & Waiver of Counsel Page 2 of 2 7.NoticeI hereby acknowledge that this notice cannot be revoked and may be admitted into evidence in an adoptionproceeding concerning the minor. 8.Waiver of Attorney Representation check all that apply I have been informed that I am entitled to be represented by an attorney who does not represent an adoptiveparent or an agency to which my child is being relinquished.I fully understand that these proceedings may result in the TERMINATION OF MY LEGAL RELATIONSHIP WITHMY CHILD AND ALL MY PARENTAL RIGHTS AND RESPONSIBILITIES.I fully understand my RIGHT TO AN ATTORNEY. I understand that if I want an attorney and cannot afford tohire an attorney at my own expense, an attorney will be appointed to represent me at no cost to me.I DO NOT WISH TO BE REPRESENTED BY AN ATTORNEY and I hereby waive my right to be represented by anattorney in this proceeding.Please send all correspondence to me at the address below. Dated Signature of Parent Mailing Address Town/City State Zip Phone Number Subscribed and sworn before me on: My commission expires on: Signature of Notary Public or Person Authorized by Probate Court Printed Name American LegalNet, Inc. www.FormsWorkFlow.com