Free CCCO 0009 9-21-07.pmd - Illinois

Affidavit of Agency

(This form replaces CO-3)

(Rev. 9/21/07) CCCO 0009 A

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN THE MATTER OF THE PETITION OF

__________________________________________________
and

__________________________________________________
TO ADOPT:

__________________________________________________

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No. ______________________________

AFFIDAVIT OF AGENCY (2808)
1. The following is a statement of expenses incurred or to be incurred by Agency in the above-captioned adoption: NAME Hospital __________________________________________________________ Obstetrician ______________________________________________________ Pediatrician ______________________________________________________ Other Medical Expenses _____________________________________________ AMOUNT $ ______________________

______________________ ______________________ ______________________ ______________________ ______________________

_________________________________________________________________
Other Expenses (Specify) ____________________________________________ TOTAL 2.

0.00 $ ______________________

The following is a statement of contributions, fees or other compensation received by or promised to Agency: DESCRIPTION AMOUNT $ ______________________

Contribution promised by adoptive parents Amount of contribution paid to date Fees billed to adoptive parent(s) Amount of fees paid to date Compensation received from other sources: (Identify) _________________________________________________________ Compensation or contribution promised by other sources: (Identify) ________________________________________________________________

______________________
__________________________

______________________ ______________________ ______________________
(OVER)

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS

(This form replaces CO-3)

(Rev. 9/21/07) CCCO 0009 B

3. The adopting parent(s) must pay the following expenses directly to billers, and the Agency has or will so inform the adopting parent(s). NAME Hospital ________________________________________________________ Obstetrician_____________________________________________________ Pediatrician ____________________________________________________ Other Medical Expenses ___________________________________________ AMOUNT $ __________________________

__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

_______________________________________________________________ _______________________________________________________________
Psychologist, Psychiatrist or Therapist _______________________________

_______________________________________________________________ _______________________________________________________________
Attorneys, other than Attorney of Record for adoption:

_______________________________________________________________ _______________________________________________________________
Travel Expenses _________________________________________________ Visas, Passports, Foreign documents _________________________________ Other agency or governmental body _________________________________ Other Expenses: _________________________________________________

__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

_______________________________________________________________ _______________________________________________________________
4. This (is) (is not) a subsidized adoption.
(Strike inapplicable)

CERTIFICATION

Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this Affidavit are true and correct.

Dated: ________________________

(Signed) ______________________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS