AFFIDAVIT OF BIOLOGICAL PARENT - ADOPTION 3268 (Rev. 06/07) UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT STATE OF ILLINOIS COUNTY OF DU PAGE IN THE MATTER OF THE PETITION OF [make this fill field bold and centered] AND [center this fill field] CASE NUMBER [make this fill field bold and centered] TO ADOPT AFFIDAVIT OF BIOLOGICAL PARENT [make this fill field bold and centered] File Stamp Here Each parent must complete a separate affidavit. This affidavit is not to be completed in case of agency placement. I, am the (relationship) of 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 or other things of value: From Whom Amount Reason Received Promised $ Received Promised $ Received Promised $ 3. I have paid or expect to pay: Amount Paid Expect to Pay Name $ Paid Expect to Pay Obstetrician $ Paid Expect to Pay Medicine $ Paid Expect to Pay Other Medical Expenses $ Paid Expect to Pay Other Expenses (specify) $ OATH being duly sworn on oath and under penalty of perjury, state that I have read the above affidavit of biological parent and know that the contents thereof are true. Signed and sworn to before me [center this fill field] Date Signature Circuit Clerk or Notary Public CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT © WHEATON, ILLINOIS 60189-0707 American LegalNet, Inc. www.FormsWorkflow.com