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:
__________________________________________________
}
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