IN THE CIRCUIT COURT OF THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS IN RE: ADOPTION OF _____________________________________ ) ) ) CASE NO.___________________________ AFFIDAVIT __________________________________________________________ on oath, and under penalty of perjury, states: 1. That Affiant is involved in the adoption as: a) Agency: _________________________________________ b) Natural parents of child sought to be adopted. c) Petitioner. d) Attorney. e) Other. Affiant has: a) b) c) d) e) been given been promised received paid promised to pay 2. the following in connection with this adoption: Hospital: Physician: Medicine: Other Medical Expenses: Maternity Home: Agency Fee: Attorney's Fees: Court Costs: Guardian ad Litem Fees: Other: $________ $________ $________ $________ $________ $________ $________ $________ $________ $________ ___________________________________________ (Affiant) Subscribed and sworn to before me on this date: _____________________________________. _____________________________________ Notary Public Affidavit Rev. 04-01-16 American LegalNet, Inc. www.FormsWorkFlow.com