Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 1 of 3 þ en-USI, þ , the mother of a (select one) þ Male þ en-US1. þ en-US County of þ State of þ en-US . 2. That I live at þ en-US County of þ State of þ en-US . 3. That I am þ en-US years of age. 4. en-USen-US en-US He is þ þ þ en-US or he is deceased, having died on þ in the State of þ en-US . B. en-USen-US Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 2 of 3 C. en-USen-US 5. en-US en-US en-US 6. en-USthe father of my child. þ en-US in the Circuit Court located in þ en-US 7. þ þ Yes þ B. en-US þ Yes þ þ en-US C. en-US þ þ Yes þ D. þ Yes þ E. þ Yes þ F. þ Yes þ G. þ Yes þ H. en-US þ þ Yes þ þ en-USen-USnecessary.) þ Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 3 of 3 8. en-US 9. en-US en-USen-USen-USen-US 11. en-USen-USand voluntary act and understand the contents and the results of signing it. þ en-USen-US þ en-US en-USSignature of Biological Mother en-USSignature of Biological Mother