COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Probate .Court Form 135 .... .. .. : Waiver of Counsel Index No. : Calendar No. PROBATE COURT : STATE OF VERMONT DISTRICT OF _______________________Plaintiff(s) JUDICIAL SUBPOENA -against- :DOCKET NO. ___________________ IN RE THE ADOPTION OF __________________________ : : WAIVER OF COUNSEL 15A Defendant(s) V. S. A. 3 -503(b)(1) : ...................................................... I, ____________________________________, have been informed that I am entitled to be represented by an attorney who is not representing an adoptive parent or an agency to which the parent’s child is being relinquished. THE PEOPLE OF THE STATE OF NEW YORK I fully understand that these proceedings may result in the TERMINATION OF MY TO RELATIONSHIP TO MY CHILD. I fully understand my RIGHT TO AN ATTORNEY, and it has been explained to me that an attorney will be appointed to represent me if I want an attorney and cannot afford to hire an attorney at my GREETINGS: own expense. WE COMMAND YOU, that TObusiness and excuses beingAN ATTORNEY, and I hereby waive before However, I DO NOT WISH all BE REPRESENTED BY laid aside, you and each of you attend , the Honorable represented by an attorney in this proceedings. at the Court my right to be located at County of in room Please send all correspondence to me at the addressat , on the day of , 20 , below. o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Signature : ________________________________ Date: ________________________________ Address: to comply with this subpoena is punishable as a contempt of court and will make you liable to ________________________________ Your failure the party on whose behalf________________________________ this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ________________________________ result of your failure to comply. Telephone: Home ( ) _______________________ Work ( ) _______________ Witness, the presence , by of Probate Court. Signed inHonorable of a Notary Public or other person authorizedone thethe Justices of the Court in County, day of , 20 Subscribed and sworn to on this ____________________ day of ___________________, below) (Attorney must sign above and type name 20_____. Before me, Attorney(s) for _______________________________________ Notary Public, Judge Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com