I E t r 2 107-B @ ) 2D STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT COUNTY IN THE MATTER OF THE PETITION OF No. AND TO ADOPT AFFIDAVIT OF PERSON MAKING PLACEMENT* I, (City and State) , , residing at (Name of Person) , a(n) with or employed by (Address) (Occupation) affiliated , arranged the placement of the child in the home of the petitioners. 1. How did you learn of the availability of the child? I 2. What is your relation to adopting parents? (Friend, relative, client, patient, etc.) (If none, how did you learn about them?) 3. How did you learn the adopting parents wanted a child? 4. What expenses have you incurred or anticipate incurring? ITEMIZE AMOUNT $ TOTAL $ • This Affidavit is not to be completed by personnel of child welfare agency or biological parents. If Attorney of Record for adoption proceedings made the placement, such attorney must also complete this Affidavit. American LegalNet, Inc. www.USCourtForms.com 5. Name any person or organization, including yourself who has or expects to receive any fees, gifts, donations or reimbursements, directly or indirectly, from adopting parent(s) for placing the child and the reason for payment. ITEMIZE AMOUNT $ TOTAL $ 6. Fees or expenses billed or to be billed to biological parent(s), amount, and reason for billing: ITEMIZE AMOUNT $ TOTAL $ 7. Money, gifts, donations or reimbursements paid or promised to biological parent(s): ITEMIZE AMOUNT $ TOTAL $ 8. Name any person or organization, including yourself, who has received or been promised money, gifts, donations, fees or reimbursements, directly or indirectly, from adopting parent(s) for placing the child. ITEMIZE AMOUNT $ TOTAL $ (SIGNED) (Name and Title) Signed and sworn to before me , 20 (Notary Public) American LegalNet, Inc. www.USCourtForms.com