700-00135 Waiver of Counsel () Page 1 of 1 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No. In r e Adoption of : WAIVER OF COUNSEL 15A V.S A. 3 -503(b)(1) I have been informed that I am entitled to be represented by an attorney who does not represent an adoptive parent 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 TO MY 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 to hire an attorney at my own expense, an attorney will be appointed to represent me at no cost to me. However, I DO NOT WISH TO BE REPRESENTED BY AN ATTORNEY, and I hereby waive my right to be represented by an attorney 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 S ubscribed 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