S.S.L. § 374(6); 22 NYCRR 205.53(b)(8) Form 9-A (Affidavit of Financial Disclosure - Parents - Agency) 9/99 COURT OF THE STATE OF NEW YORK COUNTY OF ________________________________ In the Matter of the Adoption of A Child whose First Name is (Docket)(File) No. AFFIDAVIT OF FINANCIAL DISCLOSURE PARENTS (Agency) _________________________________ STATE OF NEW YORK COUNTY ) ss: ) (and being duly sworn, depose(s) and say(s): 1. That deponent(s) reside(s) at and (is)(are) the (petitioning adoptive parent(s) (birth or legal parent(s)) of the above-named adoptive child; and 2. That deponent(s) (has)(have) paid or given or caused to be paid or given or undertaken to pay or give the following expenses, contributions, compensation or things of value, either directly or indirectly, to any person, agency, association, corporation, institution, society or organization, in connection with the placing out of said adoptive child with deponent(s) or with the adoption of said child by deponent(s): [Specify recipient, amount, form, and purpose of each payment. If none, so state.] ) ; 3. That deponent(s)(has)(have) requested, received or accepted, either directly or indirectly, the following compensation or things or value from any person, agency, association, corporation, institution, 2001 © American LegalNet, Inc. Form 9-A page 2 society or other organization in connection with the placing out of said adoptive child with deponent(s) or with the adoption of said child by deponent(s). [Specify source, amount, form and purpose of each payment requested or received. If none, so state.] ________________________________________________________/_______________________ *(Adoptive) (Birth)(Legal) Parent: typed or printed name/ signature _________________________________________________________/______________________ *(Adoptive)(Birth) (Legal) Parent: typed or printed name/ signature ______________________________________/_________________________________________ *Attorney if any: typed or printed name/signature ________________________________________________________________________________ *Attorney's Address and Telephone number Sworn to before me this day of , . _______________________________ Judge of the Court ______________________________ *Delete inapplicable provisions 2001 © American LegalNet, Inc.