Affidavit of Person Making Placement (This form replaces CCCO-0000 A1) (Rev. 3/26/13) CCCO 0007 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 PERSON MAKING PLACEMENT (2817) I, ___________________________________________ residing at ___________________________________________, __________________________________________________, a(n) _______________________________________ affiliated with or employed by _____________________________________________________________________________________ arranged the placement or transmitted information concerning the availability of the child to the petitioners or their agent. 1. State in specific detail how you learned of the availability of the child? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 2. What is your relation to the adopting parents? (Friend, relative, patient, etc.) If none, how did your learn about them? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 3. How did you learn the adopting parents wanted a child? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 4. What expenses have you incurred or do you anticipate incurring? ITEMIZE ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ AMOUNT $ _______________________ $ _______________________ $ _______________________ (OVER) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (Rev.3/26/13) CCCO 0007 B 5. Name any person or organization, including yourself, who has or expects to receive any fees, gifts, donation or reimbursements, directly or indirectly, from adopting parent(s) or their agent, and the reason for the payment. ITEMIZE ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 6. AMOUNT $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ Money gifts, donations or reimbursements paid or promised to be paid to the bioligical parents, whether by the adopting parents or any other persons: ITEMIZE ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ AMOUNT $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ CERTIFICATIONS 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) ______________________________________________ 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 PERSON MAKING PLACEMENT, and that the contents thereof are true and correct to the best of his/her knowledge, information and belief. Atty. No: ____________________________________ Name: ______________________________________ Atty. for: ____________________________________ Address: ____________________________________ City/State/Zip: _______________________________ Telephone: __________________________________ Email address: _______________________________ (Signed) _______________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS