(Rev. 3/27/01) CCCO 0601 A 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 BIOLOGICAL PARENT* I, ____________________________________________, am the ________________________________________________ (relationship) ______________________________________________________________________________________________, a minor. 1. Give the name and address of the person or organization which made arrangements to place your child with adopting parents and how you heard of that person or organization: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 2. I have received or have been promised the following contributions, compensation, money reimbursement, gifts, or other things of value FROM WHOM AND REASONS FOR PAYMENTS AMOUNT _______________________________________________________________ $ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ 3. I have paid and expect to pay: NAME AMOUNT Hospital _______________________________________________________ $ _______________________________ Obstetrician ____________________________________________________ _______________________________ Medicine _______________________________________________________ _______________________________ Other Medical Expenses __________________________________________ _______________________________ _______________________________________________________________ _______________________________ Other Expenses (Specify) __________________________________________ _______________________________ _______________________________________________________________ _______________________________ _______________________________________________________________ _______________________________ *Each parent must complete a separate Affidavit. Affidavit not to be completed in case of agency placement. ________________________________________________ (Name) (OVER) (Rev. 3/27/01) CCCO 0601 B 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: _______________________________, _________ (SIGNED) ______________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form