ADOPT-230 Clerk stamps date here when form is filed. Adoption Expenses If you are adopting your stepchild, do not fill out this form. 1 Your name (adopting parent): a. b. Relationship to child: Address (skip this if you have a lawyer): Street: State: Zip: City: ) Telephone number: ( Lawyer (if any): (Name, address, telephone number, and State Bar number): Fill in court name and street address: Superior Court of California, County of Fill in case number if known: Case Number: 2 Name of child after adoption: 3 List the services you received that were related to the adoption of the child listed in 2 : Service a. Hospital Name and address of service provider How much paid, or value of service $ Payment date b. Prenatal care $ c. Legal fees paid $ d. Adoption agency fee paid e. Transportation $ $ f. Adoption facilitator fees paid $ Judicial Council of California, www.courtinfo.ca.gov Revised January 1, 2007, Mandatory Form Family Code, § 8610 Adoption Expenses ADOPT-230, Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case Number: Your name: How much paid, or value of service $ Service g. Counseling fees paid Name and address of service provider Payment date h. Adoption service provider i. Pregnancy expenses paid j. Court filing fees paid $ $ $ k. Fingerprinting fees paid l. Other $ $ If you need more space, attach a sheet of paper and write "ADOPT-230, Item 3--Payment for Services" at the top. Number of pages attached: 4 I declare under penalty of perjury under the laws of the State of California that I have listed all payments (or anything of value) that I have paid or agreed to pay, or that were paid on my behalf, related to the child I want to adopt. I declare under penalty of perjury under the laws of the State of California that the information in this form is true and correct, which means that if I lie on this form, I am guilty of a crime. Date: Type or print your name Signature of adopting parent Date: Type or print your name Signature of adopting parent Revised January 1, 2007 Adoption Expenses ADOPT-230, Page 2 of 2