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