ADOPTIVE PARENTS FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-612 REV. 3/03 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] RECORDED (CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF DISTRICT NO. ,AN IDENTIFIED ADOPTION AFFIANT(S)[Person(s) signing and swearing to this affidavit] CHILD-PLACING AGENCY OR DEPARTMENT [Include name and address.] DATE OF AFFIDAVIT DATE OF CHILD'S PLACEMENT IN ADOPTIVE HOME This affidavit is the PRELIMINARY AFFIDAVIT [Represents financial status when child is placed with prospective adoptive parents and is submitted to placing agency.] The affiant(s) hereby swear, affirm, or aver that: We are FINAL AFFIDAVIT [Represents financial status as of the date of filing the application for adoption with the probate court, and this affidavit is submitted therewith.] I am the prospective adoptive parent(s) of the child who has been identified for adoption in the above-captioned matter. To the best of our my knowledge and belief, no payments have been made or promised to be made directly or indirectly, to any person by any person(s) involved in this adoption, except for such permissible payments listed below, which are allowed and defined by the Department of Children and Families' Regulations 45a-728-1 et seq. entitled, "Adoption Placement of Children Who Have Been Identified or Located by Prospective Adoptive Parents," and made payable through an agency or agencies within or without the State of Connecticut licensed or approved by the Commissioner of Children and Families for the placement of children for the purpose of adoption. [Please complete the payments or gratuities paid or promised section below.] PAYMENTS OR GRATUITIES PAID OR PROMISED TO BE PAID TO THE CHILD-PLACING AGENCY OR AGENCIES Placing Agency Fee to Other Agency Fee to Attorney's Fees Living Expenses of Birth Mother Transportation, Lodging, and Food Expenses [Regulation 45a-728-8(b)] $ a. For Birth Parent $ b. For Agency Representative Counseling Expenses (For Birth Parent) Foster Care Expenses (For Adoptive Child) Maternity Home Expenses (Not to exceed sixty days) a. For Birth Parent b. For Adoptive Child $ $ $ $ $ $ Total of a & b $ $ $ $ $ $ $ Total of a & b $ $ TOTAL $ Other (Please provide explanation. ) ...................................................................................... Affiant's Signature Affiant's Name [Type or Print] ......................................................................................... Affiant's Signature [Type or Print] Address Telephone: SUBSCRIBED AND SWORN TO BEFORE ME DATE ...................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct. ADOPTIVE PARENTS' FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-612 American LegalNet, Inc. www.FormsWorkFlow.com