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Affidavit In Support Of Petition To Adopt Form. This is a Illinois form and can be use in Cook Local County.
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Tags: Affidavit In Support Of Petition To Adopt, CCCO 0058, Illinois Local County, Cook
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Affidavit in Support of Petition to Adopt
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(Rev. 4/11/11) CCCO 0058 A
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
COUNTY DEPARTMENT, COUNTY DIVISION
In Re Petition of:
_______________________________________________
COAD ______________________________
AFFIDAVIT IN SUPPORT OF PETITION TO ADOPT (2800)
I, __________________________________________, in support of my petition to adopt ___________________
_______________________________ do submit the following information to the Court for investigation and review.
1.
My date of birth is ___________________________________, age: ____________.
2. Have you ever been known by another name? Yes No If yes, please state those names and the date(s) and
reason for the change of name on a separate sheet of paper.
3.
My present address is: _______________________________________________________________________.
I have lived there since _______________. (If less than 5 years please state the address and dates of residence during
that time on a separate sheet of paper).
4.
My home telephone number is _______________________. My work number is _______________________.
5.
Name, age and relationship of others who live in the home: __________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________.
6.
I am married in a civil union separated; date of separation ___________________ not married.
7.
The date and place of my marriage civil union was ____________________________________________________.
8. I have have not been previously married. (If you have been married before, on a separate sheet of paper, state
the date of the marriage, the reason (divorce, death of a spouse) and exact date that the marriage ended. Note, you are
required to furnish the investigator with documentary proof that any prior marriage has ended.
9a. I am currently employed by ____________________________________ which is located at ____________
________________________________________________________. My occupation is ______________________.
My gross pay is $ ______________________. I have been employed for ___________ years. (If less than 5 years,
on a separate sheet of paper, list your place of employment during that time.)
9b. I am not currently employed. My current source(s) of income is (are) _________________________________
from which I derive an annual gross income of $ ____________________.
9c. I am retired after working ___________ years for ____________________________________________ as
a(n) ____________________________. My retirement income from all sources is $ __________________ per year.
(OVER)
(Rev. 4/11/11) CCCO 0058 B
10. I have not have (choose one) been arrested and charged with a criminal offense other than a traffic violation
punishable by fine only. (If your answer is yes, on a separate sheet of paper, list every incident for which you were
arrested, the charge, describe your involvement, the date of arrest and the court disposition.)
11. I have not have (choose one) been advised that the Department of Children and Family Services has made
an "indicated" finding for abuse or neglect of a child residing in the same household where I lived. (If your answer is
yes, on a separate sheet of paper, please list the date of every incident, the allegation, whether you were required to
attend court and the disposition.)
12. I am not am (choose one) required to register as a sex offender.
13. The names and ages of the child(ren) being adopted are: _________________________________________
____________________________________________________________________________________________.
14. I am am not related biologically or by marriage to the child(ren) being adopted or his/her parents as follows:
___________________________________________________________.
15. The child(ren) being sought for adoption have have not resided in my home. If yes. How long? _______________.
16. My religious belief is
________________________________________.
17. The child(ren)'s religious belief is/are
___________________________________________________________.
Under penalties of perjury and/or contempt of court, the undersigned certifies that the statements set
forth in this instrument are true and correct, except as to matters therein stated to be on information
and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the
same to be true.
Signed:
______________________________________
Print Name:
Date:
___________________________________
____________________________, ___________
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
