Affidavit in Support of Petition to Adopt (09/12/16) CCCO N058 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF: __________________________________________________________ and __________________________________________________________ To Adopt: __________________________________________________________ No. ________________________________ AFFIDAVIT IN SUPPORT OF PETITION TO ADOPT (2800) I, __________________________________________________ , in support of my petition to adopt ____________________________________ do submit the following information to the Court for investigation and review: 1. My date of birth is _____________________________________________ , age: __________________________ . 2. I have have not been known by any other name. If you have been known by any other name(s), please state the name(s) and date(s) and reason for the change of name: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 3. My present address is: ___________________________________________________________________________ I have lived there since ___________ (If less than 5 years please state the address and dates of residence during that time). ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. My home # is _____________________ My cell # is ____________________ My work # is __________________ . 5. Name, age and relationship of others who live in the home: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. I am married in a civil union separated; date of separation ____________________________ not married. 7. The date and place of my marriage civil union was _________________________________________________. 8. I have have not been previously married. (If you have been married before, on a separate sheet of paper, state the date of the marriage, the reason (divorce, death of a spouse) and exact date that the marriage ended. Note, you are required to furnish the investigator with documentary proof that any prior marriage has ended. 9a. I am currently employed by _____________________________________ which is located at ________________________________________. My occupation is ____________________________________ . My annual gross pay is $ ________________ . I have been employed for _____________________ years. if less than five (5) years, list your place of employment during that time. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9b. I am not currently employed. My current source(s) of income is (are) from ____________________________________________________________________________________________ from which I derive an annual gross income of $ ______________. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2 Affidavit in Support of Petition to Adopt (09/12/16) CCCO N058 B 9c. I am retired after working _______________years for __________________________________________as a(n) ___________________________ . My retirement income from all sources is $ _______________________ per year. 10. I have have not (choose one) been arrested and charged with a criminal offense other than a traffic violation punishable by fine only. (If your answer is yes, on a separate sheet of paper, list every incident for which you were arrested, the charge, describe your involvement, the date of arrest and the court disposition.) 11. I have have not (choose one) been advised that the Department of Children and Family Services has made an "indicated" finding for abuse or neglect of a child residing in the same household where I live(d). If your answer is yes, on a separate sheet of paper, please list the date of every incident, the allegation(s), whether you were required to attend court and the disposition.) 12. I am am not (choose one) required to register as a sex offender. If yes, explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ . 13. The names and ages of the child(ren) being adopted are: _________________________________________________ ____________________________________________________________________________________________ . 14. I am am not related biologically or by marriage to the child(ren) being adopted or his/her parents as follows: ____________________________________________________________________________________________ . 15. The child(ren) being sought for adoption have have not resided in my home. If yes, how long? ____________________________________________________________________________________________ . 16. My religious belief is ____________________________________________________________________________ . 17. The child(ren)'s religious belief is/are ________________________________________________________________ . Under penalties of perjury and/or contempt of court, the undersigned certifies that the statements set forth in this document are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true. Signed: ______________________________________ Print Name: ___________________________________ Date: _______________________________ Primary Email: ________________________________ Secondary Email: ______________________________ Tertiary Email: ________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 2