STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) SECONDARY PLACEMENT AFFIDAVIT 18-A M.R.S. § 9-303(a)(10) 17-A M.R.S. § 553 I/We, and am/are the petitioner(s) seeking to adopt the above named child. In accordance with 18-A M.R.S. § 9-303(a)(10) and 17-A M.R.S. § 553, that after the adoption is finalized, I/we acknowledge that the transfer of the long-term care and custody of the child without a court order is prohibited. Dated: Petitioner Dated: Petitioner STATE OF MAINE COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: ____________________________________ Attorney at Law/Notary Public/Deputy Clerk , and made oath *************************************************************************** COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: ____________________________________ Attorney at Law/Notary Public/Deputy Clerk Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com , and made oath AD-011, Rev. 10/16