STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS PRINT CLEAR IN THE MATTER OF: NOTICE TO: ___________________________________________ Alleged Father CASE NO._____________________ REQUEST FOR NOTICE TO PUTATIVE FATHER AND AFFIDAVIT To Clerk of the Circuit Court: I,________________________________________________________________________ (Name and Official Title) with whom the mother has placed or has given written notice of her intention to place a child for adoption hereby requests the Clerk of this Court to send to the putative father, pursuant to Paragraph 9.1-12a Illinois Revised Statutes, notice as follows: (1) That__________________________________________is the mother of a child ____________________________________ , ___________________, 20____. (Born or expected to be born on or about) (2) That she has informed the undersigned that______________________________ is the alleged father of said child. That she has placed or indicated her intention to place said child for the purpose of adoption. (See attached Affidavit of Mother.) That the last known address of ______________________________, is_________________________________________________________. __________________________________ (Signed) (3) (4) alleged father, Signed and sworn to before me ___________________________, 20____ __________________________________ (Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com