Print Form Affidavit of Agency Clear Form (Rev. 9/21/07) CCCO 0009 A (This form replaces CO-3) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF __________________________________________________ and __________________________________________________ TO ADOPT: __________________________________________________ } No. ______________________________ AFFIDAVIT OF AGENCY (2808) 1. The following is a statement of expenses incurred or to be incurred by Agency in the above-captioned adoption: NAME AMOUNT Hospital __________________________________________________________ $ ______________________ Obstetrician ______________________________________________________ ______________________ Pediatrician ______________________________________________________ ______________________ Other Medical Expenses _____________________________________________ ______________________ _________________________________________________________________ ______________________ Other Expenses (Specify) ____________________________________________ ______________________ TOTAL 2. 0.00 $ ______________________ The following is a statement of contributions, fees or other compensation received by or promised to Agency: DESCRIPTION Contribution promised by adoptive parents AMOUNT $ ______________________ Amount of contribution paid to date ______________________ Fees billed to adoptive parent(s) __________________________ Amount of fees paid to date ______________________ Compensation received from other sources: (Identify) _________________________________________________________ ______________________ Compensation or contribution promised by other sources: (Identify) ________________________________________________________________ ______________________ (OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev. 9/21/07) CCCO 0009 B (This form replaces CO-3) 3. The adopting parent(s) must pay the following expenses directly to billers, and the Agency has or will so inform the adopting parent(s). NAME AMOUNT Hospital ________________________________________________________ $ __________________________ Obstetrician_____________________________________________________ __________________________ Pediatrician ____________________________________________________ __________________________ Other Medical Expenses ___________________________________________ __________________________ _______________________________________________________________ __________________________ _______________________________________________________________ __________________________ Psychologist, Psychiatrist or Therapist _______________________________ __________________________ _______________________________________________________________ __________________________ _______________________________________________________________ __________________________ Attorneys, other than Attorney of Record for adoption: _______________________________________________________________ __________________________ _______________________________________________________________ __________________________ Travel Expenses _________________________________________________ __________________________ Visas, Passports, Foreign documents _________________________________ __________________________ Other agency or governmental body _________________________________ __________________________ Other Expenses: _________________________________________________ __________________________ _______________________________________________________________ __________________________ _______________________________________________________________ __________________________ 4. This (is) (is not) a subsidized adoption. (Strike inapplicable) CERTIFICATION Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this Affidavit are true and correct. Dated: ________________________ (Signed) ______________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS