UCS836 rev. 3/02 NEW YORK STATE UNIFIED COURT SYSTEM ATTORNEY'S AFFIDAVIT Agency and Private Placement Adoptions Names or other information likely to identify the birth or adoptive parents or the adoptive child are to be omitted from the information to be supplied in the attorney's statement Pursuant to 22 NYCRR 603.23; 691.23; 806.14; 1022.33 (a) Every attorney appearing for an adoptive parent, a natural parent, or an adoption agency in an adoption proceeding in the courts within this judicial department, shall, prior to the entry of an adoption decree, file with the Office of Court Administration of the State of New York and with the Court in which the adoption proceeding has been initiated, a signed statement under oath setting forth the following information (please type or print, use additional pages where necessary): Name of Attorney: Last Name: Association with firm: (if any) Business Address: Street City 4. 5. 6. 7. Telephone Number: Docket Number of Adoption proceeding: Court where adoption has been filed: (include county) The date and terms of every agreement, written or otherwise, between the attorney and the adoptive parents, the birth parents, or anyone else on their behalf, pertaining to any compensation or thing of value paid or given, or to be paid or given by or on behalf of the adoptive parents or the birth parents, including but not limited to retainer fees. (Indicate whether the agreement is in writing or oral by checking the appropriate box). Date of Agreement: Terms of Agreement: State Zip First Name Initial 1. 2. 3. q Written Agreement q Oral Agreement 8. The date and amount of any compensation paid or thing of value given, and the amount of total compensation to be paid or thing of value to be given to the attorney by the adoptive parents, the birth parents, or by anyone else on account of or incidental to any assistance or service in connection with the proposed adoption. (If the source of compensation or thing of value is the birth parents or the adoptive parents check appropriate box only; if other, specify name). Date: Compensation paid or thing of value given: Source of compensation or thing of value given: q Birth parents $ q Adoptive parents $ q Other $ (specify name) Total compensation to be paid or thing of value to be given: Source of compensation to be paid or thing of value to be given: q Birth parents $ q Adoptive parents $ q Other $ 9. (specify name) A brief statement of the nature of the services rendered: Complete items 10-11 if another attorney or attorneys will share in the fees received in connection with the proposed adoption: 10. The name and address of any other attorney or attorneys, who shared in the fees received in connection with the services or to whom any compensation or thing of value was paid or is to be paid, directly or indirectly, by the attorney. Include the amount of such compensation or thing of value. Name: Address: Compensation paid or thing of value given: Compensation to be paid or thing of value to be given: 11. The name and address of any other attorney or attorneys, if known, who received or will receive any compensation or thing of value, directly or indirectly, from the adoptive parents, birth parents, agency or other source, on account of or incidental to any assistance or service in connection with the proposed adoption. Include the amount of such compensation or thing of value, if known. If the source of compensation or thing of value is the birth or adoptive parents, check appropriate box only; if other, specify name. Name: Address: Compensation paid or thing of value given: Source of compensation: Date paid: Date paid: q Birth parents $ Specify name and address: q Adoptive parents $ q Other $ Compensation to be paid or thing of value to be given: Source of compensation: q Birth parents $ Specify name and address: q Adoptive parents $ q Other $ American LegalNet, Inc. www.USCourtForms.com Complete items 12-13 if another person, agency, association, corporation, institution, society or organization will share in the fees received in connection with the proposed adoption: 12. The name and address of any other person, agency, association, corporation, institution, society or organization who received or will receive any compensation or thing of value from the attorney, directly or indirectly, on account of or incidental to any assistance or service in connection with the proposed adoption. The amount of such compensation or thing of value. Name: Address: Compensation paid or thing of value received: $ Compensation or thing of value to be received: 13. The name and address, if known, of any person, agency, association, corporation, institution, society or organization to whom compensation or thing of value has been paid or given or is to be paid or given by any source for the placing out of or on account of or incidental to assistance in arrangements for the placement or adoption of the adoptive child. The amount of such compensation or thing of value and the services performed or the purpose for which the payment was made. If the source of compensation or thing of value is the birth parents or the adoptive parents, check appropriate box only; if other, specify name. If additional space is needed, attach separate page. Name: Address: Compensation paid or thing of value given: Source of Compensation: Date paid: mm / dd / yyyy Date paid: q Birth parents $ Specify name and address: q Adoptive parents $ q Other $ Compensation to be paid or thing of value to be given: Source of Compensation to be paid or thing of value to be given: q Birth parents $ q Adoptive parents $ q Other $ Specify name and address: Service performed or purpose of payment: 14. A brief statement as to the date and manner in which the initial contact occurred between the attorney and the adoptive parents or birth parents with respect to the proposed adoption. Date: I affirm that I have read this form, (including any attachments), in its entirety and that all statements I have made are true, to the best of my knowledge. False statements made in this affidavit are punishable under the penal law (§ 210.45). Signature: Department: District: Date: Note: Statements may be filed personally by the attorney or his/her representative at the main office of the Office of Court Administration in the City of New York, and upon such filing he/ she shall receive a date stamped receipt containing the code number assigned to the original so filed. Statements m