700-00301 226 Verified Petition for Birth Order (07/2018) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. V ERIFIED PETITION FOR BIRTH ORDER In re: Petition filed: Pre-Birth Post-Birth 1. Petitioner A Information Name: Date of Birth: Street Address: City/State/Zip: Mailing Address (if different from Street Address): City/State/Zip: Email Address: Daytime Phone: Evening Phone: Attorney Name: Attorney Phone: 2. Petitioner A is (check all that apply) The birth parent Intended parent Other: state the nature of parental relationship to the child 3. Petitioner B Information Name: Date of Birth: Street Address: City/State/Zip: Mailing Address (if different from Street Address): City/State/Zip: Email Address: Daytime Phone: Evening Phone: Attorney Name: Attorney Phone: 4. Petitioner B is (check all that apply) The birth parent Intended parent Other: state the nature of parental relationship to the child 5. Child222s Name (if filing after child born) Name: Date of Birth: 6. Respondent Information Name: Date of Birth: Street Address: City/State/Zip: Mailing Address (if different from Street Address): City/State/Zip: Email Address: Daytime Phone: Evening Phone: Attorney Name: Attorney Phone: American LegalNet, Inc. www.FormsWorkFlow.com 700-00301 226 Verified Petition for Birth Order (07/2018) Page 2 of 2 7. Respondent is (check all that apply) The birth parent Intended parent Other: state the nature of parental relationship to the child 8. Other possible parent, if any (notice will be sent) Name: Date of Birth: Street Address: City/State/Zip: Mailing Address (if different from Street Address): City/State/Zip: Email Address: Daytime Phone: Evening Phone: Attorney Name: Attorney Phone: 9. Other party is (check all that apply) The birth parent Intended parent Other: state the nature of parental relationship to the child I/We, request that a Birth Order be issued for and Parent Name Parent Name and that Parental Rights and Responsibilities be granted exclusively to them after the child is born. The facts that support my request are: Stipulated by: Stipulation Attached Date Signature of Petitioner Date Signature of Respondent Date Signature of Other Party Signed and sworn to before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com