Affidavit of Adopting Parents Original/Amended (2819) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF: _____________________________________________ and _____________________________________________ To Adopt _____________________________________________ (Rev. 3/21/13) CCCO 0002 No._______________________________ AFFIDAVIT OF ADOPTING PARENTS ORIGINAL / AMENDED (2819) A. The following are all the costs, expenses, contribution, fees, compensation, gifts or other things of value either paid, given or promised to be paid or given in this matter: ITEM AMOUNT Hospital _____________________________________________________________________ $ ______________________ Obstetrician __________________________________________________________________ $ ______________________ Pediatrician ___________________________________________________________________ $ _______________________ Other medical expenses _________________________________________________________ $ ______________________ Guardian ad Litem for child ____________________________________________________ $ ______________________ Guardian ad Litem for minor biological parent(s) __________________________________ $ ______________________ Funds paid to biological parent(s) ________________________________________________ $ _______________________ Reimbursement for medical expenses _______________________________________ $ _______________________ **Other payments or gifts already made __________________________________________ $ ______________________ **Other payments or gifts promised but not yet paid ________________________________ $ ______________________ Agency (state name) ___________________________________________________________ $ ______________________ Amount of fee, promised or already paid ____________________________________ $ ______________________ Amount of voluntary contribution, promised or already paid ___________________ $ ______________________ Other (specify) ________________________________________________________________ $ ______________________ _____________________________________________________________________________ $ ______________________ ______________________________________________________________________________ $ ______________________ _____________________________________________________________________________ $ ______________________ _____________________________________________________________________________ $ ______________________ Court costs, paid or anticipated __________________________________________________ $ ______________________ Attorney's fees ________________________________________________________________ $ ______________________ TOTAL_______ $ ______________________ **NOTE WELL. Persons who sign this Affidavit should be made familiar with the ADOPTION COMPENSATION PROHIBITION ACT, 720 ILCS 525/0.01. (OVER) (Rev. 3/21/13) CCCO 0002 B B. State in specific detail how you learned of the availability of this child. ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________ CERTIFICATION Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certify that the statements set forth in this Affidavit are true and correct. Dated: ___________________________ ___________________________________________ ___________________________________________ Petitioner(s) CERTIFICATION OF ATTORNEY OF RECORD Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that s/he has read and reviewed the AFFIDAVIT OF ADOPTING PARENTS, and that the contents thereof are true and correct to the best of his or her knowledge, information and belief. Atty. No.:__________________ Name: ___________________________________________ Atty. for: _________________________________________ Address: _________________________________________ City/State/Zip: _____________________________________ Telephone: _______________________________________ E-mail address:____________________________________ Signed __________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS