Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Number:
IN THE MATTER OF:
DOB:
RIGHT TO AN ATTORNEY IN A TERMINATION OF PARENTAL RIGHTS CASE
REQUEST FOR COURT-APPOINTED ATTORNEY OR
WAIVER OF RIGHT TO AN ATTORNEY
I,
, of
,
Name
Address
being the
of
, a minor
Relationship
Child's Name(s)
child, have been notified to appear before the court to answer to a petition to terminate my parental
rights pursuant to the RSA 170-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 & Application for Court
Appointed Counsel (NHJB 2313-DSSup) form and this Right to an Attorney form and submit both
to the court listed on the front of the petition. 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 orders that my parental rights be terminated, I will
no longer have any legal rights, privileges, duties or obligations regarding my child including, but not
limited to, rights to custody, visitation and communication with my child. I understand that if my
parental rights are terminated, I will receive no notice of any future legal proceedings concerning my
child.
NHJB-2233-DF (07/01/2011)
Page 1 of 2
Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Number:
IN THE MATTER OF:
DOB:
RIGHT TO AN ATTORNEY IN A TERMINATION OF PARENTAL RIGHTS CASE
REQUEST FOR COURT-APPOINTED ATTORNEY OR
WAIVER OF RIGHT TO AN ATTORNEY
I,
, of
,
Name
Address
being the
of
, a minor
Relationship
Child's Name(s)
child, have been notified to appear before the court to answer to a petition to terminate my parental
rights pursuant to the RSA 170-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 & Application for Court
Appointed Counsel (NHJB 2313-DSSup) form and this Right to an Attorney form and submit both
to the court listed on the front of the petition. 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 orders that my parental rights be terminated, I will
no longer have any legal rights, privileges, duties or obligations regarding my child including, but not
limited to, rights to custody, visitation and communication with my child. I understand that if my
parental rights are terminated, I will receive no notice of any future legal proceedings concerning my
child.
NHJB-2233-DF (07/01/2011)
Page 1 of 2
Case Number:
RIGHT TO ATTORNEY – TPR
Please check one (1) of the three (3) boxes below and sign and date the form.
1.
I will hire an attorney to represent me.
2.
I do not think that I can afford to hire an attorney and would like to apply for a court-
appointed attorney. My completed Financial Affidavit & Application for Court
Appointed Counsel 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.
I have read and understand each of the statements below and have initialed each statement
indicating I understand:
I am giving up my right to have an attorney assist me with the processing of this case which
involves important legal, procedural and constitutional matters, including the examination of
witnesses, offering of testimony and presentation of evidence.
If at the end of the case the court orders that my parental rights be terminated, I will no longer
have any legal rights, privileges, duties or obligations regarding my child including, but not limited
to, rights to custody, visitation and communication with my child. I understand that if my parental
rights are terminated, I will receive no notice of any future legal proceedings concerning my child.
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. I have determined s/he understands the rights s/he is giving up by waiving
counsel and understands the consequences of a court order terminating her/his parental rights.
So Ordered:
Date
Signature of Judge
Printed Name of Judge
NHJB-2233-DF (07/01/2011)
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