AGENCY OR DEPARTMENT FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-613 REV. 3/03 TO: COURT OF PROBATE, IN THE MATTER OF STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] RECORDED (CONFIDENTIAL VOLUME): DISTRICT NO. ,AN IDENTIFIED ADOPTION AFFIANT [Person signing and swearing to this affidavit] CHILD-PLACING AGENCY OR DEPARTMENT [Include name and address.] ,AN AUTHORIZED REPRESENTATIVE DATE OF AFFIDAVIT DATE OF CHILD'S PLACEMENT IN ADOPTIVE HOME This affidavit is the PRELIMINARY AFFIDAVIT FINAL AFFIDAVIT [Represents financial status when child is placed [Represents financial status as of the date of filing the with prospective adoptive parents and is submitted application for adoption with the probate court, and this to placing agency.] affidavit is submitted therewith.] The affiant hereby swears, affirms, or avers that: I am a duly-authorized representative of the Department of Children and Families or of the agency listed above that is licensed or approved by the Commissioner of Children and Families for the placement of children for the purpose of adoption. To the best of my knowledge and belief, the agency or department listed above has received is to receive only those payments or gratuities listed herein from the prospective adoptive parent(s), or anyone on their behalf, in connection with the identified adoption as 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." TYPE RECEIVED OR EXPECTED FROM DATE $ $ $ Total $ [Use Second Sheet, PC-180, if necessary.] To the best of my knowledge and belief, the agency or department listed above has made will make only the following expenditures on behalf of the birth parent(s), prospective adoptive parent(s), or any other person or group of persons associated in any way with this identified adoption. AGENCY OR DEPARTMENT EXPENDITURES[ Continue on Second Sheet, if necessary.] 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 Other (Please provide explanation. ) $ $ $ $ Total of a & b $ $ $ $ $ $ $ Total of a & b $ $ TOTAL $ ................................................................................. Affiant: Name of Agency or Department: Authorized Representative: Signature................................................................................................... Telephone: SUBSCRIBED AND SWORN TO BEFORE ME DATE ................................................................................. Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct. American LegalNet, Inc. www.FormsWorkFlow.com Static Text Title AGENCY OR DEPARTMENT FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-613