Voluntarily Mediated Agreement

In the case of the involvement of a minor under the legal guardianship of the Department of Health and Human Services in a dispute, a mandatory mediation session can be held to reach an agreement regarding the place of permanent placement of the involved child. To ask for mediation, the following form has to be submitted:

Extracted Text for Proper Search

NHJB-2302-FP (10/01/2006) Page 1 of 2 
 	THE STATE OF NEW HAMPSHIRE	 	
JUDICIAL BRANCH 
http://www.courts.state.nh.us	 	
 	
 
Court Name: 
Case Name: 
Case Number: 	
  (if known)  	
 
 
 	
VOLUNTARILY MEDI ATED AGREEMENT 	
(RSA 170-B:14) 
 
1.  This agreement is entered into pursuant  to the provisions of RSA 170-B:14, II. 
2.  Any breach, modification, or invalidation of this agreement, or any  part of it, shall not affect the 
validity of the surrender of parent al rights or the interlocutory or final decree of adoption. 
3.  The parties acknowledge that both the  birth and prospective adoptive parents who have 
entered into the agreement  have the right to seek enforcement as set forth in RSA-170-B:14, 
II(i). 
4.  The parties have not relied  on any representations other than those contained in this 
agreement. 
5.  This agreement was entered in to knowingly and voluntarily and is not the product of coercion, 
fraud, or duress.

Case Name:  	 
Case Number:  
 
VOLUNTARILY MEDIATED AGREEMENT 
 	
NHJB-2302-FP (10/01/2006)  Page 2 of 2 
  	 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
  
 
 
This agreement is signed  as my free act and deed. 
 
  	
    	  	 	
Date    Birth Mother    Birth Father 
  	    	  	 	
Date        Attorney for Birth Mother    Attorney for Birth Father 
  	    	  	 	
Date    Adoptive Mother  Adoptive Father 
  	    	  	 	
Date        Attorney for Adoptive Mother    Attorney for Adoptive Father 
  	    	  	
Date    Div. for Children, Youth & Families 
 
State of     	
, County of        	 
This instrument was ack nowledged before me on      	
 by          	 
My Commission Expires  	
  	 
Affix Seal, if any           	
Signature of Notarial Officer / Title	 
 
  CHILD'S ASSENT 
I am the child mentioned in this  agreement, I am 14 years of age or older , and I give my assent to this 
voluntarily mediated agreement. 
     	
         	 	
Date       Child Signature 
 
This agreement is approved. 
   	       	     	 	
Date     Judge signature     Printed name