STATE OF ILLINOIS) )SS COUNTY OF WILL ) IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS IN THE MATTER OF THE PETITION OF __________________________________________ AND______________________________________ TO ADOPT __________________________________________ CASE NO.________________________ AFFIDAVIT OF BIOLOGICAL PARENT* I,__________________________________________________, am the_________________________________________ of (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. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _____________________________________________________________ I have received or have been promised the following contributions, compensation, money, reimbursement or other things of value: FROM WHOM AND REASON FOR PAYMENT AMOUNT ___________________________________________________________ ___________________ ___________________________________________________________ ___________________ ___________________________________________________________ ___________________ ___________________________________________________________ ___________________ ___________________________________________________________ ___________________ TOTAL $__________________ I have paid and expect to pay: NAME Hospital____________________________________________________ Obstetrician_________________________________________________ Medicine___________________________________________________ Other Medical Expenses_______________________________________ ___________________________________________________________ Other Expenses (Specify)______________________________________ ___________________________________________________________ TOTAL 2. 3. AMOUNT $__________________ ___________________ ___________________ ___________________ ___________________ ___________________ $__________________ ________________________________________ Signed and sworn to before me __________________________________, 20___ _________________________________________ (Notary Public) (Name of Biological Parent) *Each Parent must complete a separate Affidavit; however, Affidavit is not to be completed in case of Agency placement. 2000 © American LegalNet, Inc.