PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the ADOPTION of:_____________________________________________________________________ (Name after adoption) Case No._____________________ Date:______________________________ AFFIDAVIT The undersigned does hereby sate that she makes no requirements or requests as to the religion of the adoptive parents. My concern is that the baby be placed in a home of comparable physical and educational background with reasonable financial security. Further, the following statements are made to the best of my knowledge: 1. I have not filed any proceeding under 3111.01 or 311.03 of the Revised Code (paternity action) against any male person at any time before the placement of the minor in the home of the Petitioner. 2. No male person has ever filed an application with any Probate Court before the placement of the minor in the home of the Petitioner declaring that this child is his child and asking that the child be declared his legitimate child, or signed an acknowledgement of paternity. 3. No male person has signed the birth certificate as an informant as provided in Section 3705.14 of the Revised Code . 4. No male person has filed an objection to the adoption. 5. I have not accepted any gifts of any nature nor have any been promised to me in order to complete this placement. 6. I am aware that an action to contest the Decree of Adoption can be filed within one year after it is issued but that after the expiration of one year, the Decree cannot be questioned by any person unless, in the case of the adoption of a minor, the Petitioner has not taken custody of the minor. 7. I have truthfully completed the social and medical history required by O.R.C. 3107.12 and filed it with the Court. 8. I understand that the social and medical history can be corrected or expanded in the future. 9. I understand that I can consent to the release of identifying information to my birth child. I acknowledge receipt of the "Authorization for Release" form prescribed by the Ohio Department of Health, Division of Vital Statistics. 10. I consent to the adoption of my child with the prospective adoptive parents. 11. I understand that my consent to adoption is irrevocable and cannot be withdrawn after the entry of an interlocutory order or after the entry of a final decree of adoption. 12. I presently reside at _____________________________________________________, and have resided there for ____ years. My previous residence was ___________________________________________. 13. The natural father of the child is known to me, whose name is __________________________________ and address is _______________________________________________________________________. ______________________________________ Affiant Sworn to before me, a notary public, this ______ day of ______________________, 20____. ______________________________________ Notary Public Crensch$\forms \19.3 FORM 19.3 - AFFIDAVIT 193 American LegalNet, Inc. www.USCourtForms.com