AFFIDAVIT OF PERSON MAKING PLACEMENT - ADOPTION STATE OF ILLINOIS UNITED STATES OF AMERICA IN THE CIRCUIT COURT OF THE EIGHTEENTH JUDICIAL CIRCUIT 3270 ( Rev. 06/07) 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 [make this fill field bold and centered] 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, am affiliated with reside at 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? Incurred Incurred Incurred Incurred Anticipate Anticipate Anticipate Anticipate $ $ $ $ Amount 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 American LegalNet, Inc. www.FormsWorkflow.com