State Of Maine Declaration Page printable pdf download

State Of Maine Declaration Page

STATE OF MAINE

DECLARATIONS PAGE

(for gestational carrier agreements)

 Pursuant to Title 19-A M.R.S.A. § 1932(3)(G) Health care providers must rely upon

this document alone which establishes the intended parents as the legal parents from

the moment of birth including but not limited to authority for all medical decisions for

the child, health care expenses, discharge, establishment of birth certifications and any

and all parental rights and responsibilities. A pre-birth or post birth order may, but is

not required, to accompany this document.

This is in reference to an agreement dated ____________________________________, by and

between (parent) ____________________________(co-parent)

________________________,

herein after known as Parents, and ______________________________________, herein known as

Gestational Carrier and (if applicable), her spouse, _____________________. All parties have

independent legal counsel as listed below. This Declarations Page is pursuant to the Maine

Parentage Act, Title 19A. Section 1932 (3) (G), regarding the establishment of parental rights

and responsibilities pursuant to a valid gestational carrier agreement and the attorneys below

state that the agreement referenced above meets the requirements of the Maine Parentage

Act.

Signature of Legal Counsel for Parents: ___________________________________ Date:_______________

Print Name:

Address:

Phone:

State licensed in and Bar Number:

_______

Signature of Legal Counsel for Gestational Carrier: ___________________________Date:______________

Print Name :

Address:

Phone:

State licensed in and Bar Number:

This Declarations Page shall be submitted to health care providers after confirmation of the pregnancy

and prior to or as soon as possible near the time of the birth of the child. Birth records shall list the above

Parent(s) as the child(s) parents, and, at the moment of birth the above Parent(s) have all parental rights

and responsibilities.

State Of Maine Declaration Page