BIRTH MOTHER'S FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-611 REV. 3/03 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink.] [File in duplicate.] RECORDED (CONFIDENTIAL VOLUME): TO: COURT OF PROBATE, IN THE MATTER OF DISTRICT NO. ,AN IDENTIFIED ADOPTION AFFIANT AGENCY OR DEPARTMENT [Include name and address.] [Person signing and swearing to this affidavit] DATE OF AFFIDAVIT DATE OF CHILD'S PLACEMENT IN ADOPTIVE HOME [If known] The affiant hereby swears, affirms, or avers that: I am the birth mother of the child who has been identified for adoption in the above-captioned matter. To the best of my knowledge and belief, no payments have been made or promised, directly or indirectly, to me or any other person by any person(s) involved in this adoption, except for those payments made by the agency or agencies placing the child in adoption. .......................................................................... Affiant's Signature Affiant's Name [Type or print] Address and zip code: Telephone Number(s): SUBSCRIBED AND SWORN TO BEFORE ME ..................................................................................... Judge, Ass't Clerk, Notary Public, Comm. Sup. Ct. BIRTH MOTHER'S FINANCIAL AFFIDAVIT/ IDENTIFIED ADOPTION PC-611 DATE American LegalNet, Inc. www.FormsWorkFlow.com