STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) REPORT OF DISBURSEMENTS 18-A M.R.S. § 9-306(a) Petitioner(s) do/does certify under oath that the following disbursements and expenses have been or will be paid by or on behalf of me/us in connection with this adoption, and that this report is a full accounting of all disbursements and payments made in connection with this adoption, including all payments in cash or transfers of anything of value. For each service provided, include the following: A) name and address of payee; B) amount or value that payee received; and, C) date of payment or transfer. Legal services provided to legal parent 1 in connection with surrender and release, consent, or adoption process. _______________________________________________________________ ______________________________________________________________________________ Legal services provided to legal parent 2 in connection with surrender and release, consent, or adoption process. _______________________________________________________________ ______________________________________________________________________________ Counseling services provided to legal parent 1 in connection with surrender and release, consent, or adoption process. _____________________________________________________ ______________________________________________________________________________ Counseling services provided to legal parent 2 in connection with surrender and release, consent, or adoption process. ______________________________________________________ ______________________________________________________________________________ Prenatal, birthing, and other related medical expenses for the birth mother. ______________________________________________________________________________ ______________________________________________________________________________ Transportation expenses associated with any of the above services. ______________________ ______________________________________________________________________________ Foster care expenses for the child. ____________________________________________ ______________________________________________________________________________ Living expenses for the birth mother. ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other (Also include here the name and address of any other persons or entities who AD-007, Rev. 07/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com participated in any way in the handling of funds associated with this adoption, either directly or indirectly.) _____________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PLEASE NOTE: Report of disbursements is not required when one of the petitioners is a blood relative. Dated: Petitioner Dated: Petitioner STATE OF MAINE COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: ____________________________________ Attorney at Law/Notary Public/Deputy Clerk , and made oath *************************************************************************** COUNTY Personally appeared the above-named that the foregoing statements are true. Before me, Date: ____________________________________ Attorney at Law/Notary Public/Deputy Clerk , and made oath AD-007, Rev. 07/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com