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Affidavit Of Person Making Placement Form. This is a Illinois form and can be use in Dupage Local County.
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Tags: Affidavit Of Person Making Placement, 3270, Illinois Local County, Dupage
AFFIDAVIT OF PERSON MAKING PLACEMENT - ADOPTION
3270 ( 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
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AND
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CASE NUMBER
TO ADOPT
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AFFIDAVIT
OF PERSON MAKING PLACEMENT
File Stamp Here
This affidavit is NOT to be completed by personnel of a child welfare agency of the biological parents. If the attorney of record for the
adoption proceedings made the placement, such attorney must also complete this affidavit.
I,
reside at
am
affiliated with
,
employed by and arranged the placement in the home of the petitioners.
1. How did you learn about the availability of the child?
2. What is your relationship to the adopting parents? (friend, relative, client, patient?) If none, how did you learn about
them?
3. How did you learn that the adopting parents wanted a child?
4. What expenses have you incurred or do you anticipate incurring?
Amount
Incurred
Anticipate
$
Incurred
Anticipate
$
Incurred
Anticipate
$
Incurred
Anticipate
$
5. Name any person or organization, including yourself, who has or expects to receive any fees, gifts, donations or
reimbursements, directly or indirectly from the adopting parent(s) for placing the child and the reason for payment.
CHRIS KACHIROUBAS, CLERK OF THE 18th JUDICIAL CIRCUIT COURT ©
WHEATON, ILLINOIS 60189-0707
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