Free CCCO 0032 2-21-08.pmd - Illinois

Affidavit of Identification IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION

(Rev. 2/21/08) CCCO 0032 A

AFFIDAVIT OF IDENTIFICATION (2807)
I, ______________________________________, the mother of a (select one) or affirm as follows: 1.
(Date)

male

female child, state under oath

That the child was born, or is expected to be born, on _______________________, ________ at ______________

____________________________________, in the State of ____________________.
2. That I reside at _______________________________________________ in the City/Village _________________ of State of ____________________. 3. 4. 5. That I am of the age of _______________ years. That I acknowledge that I have been asked to identify the father of my child. (Check one.)

I know and am identifying the biological father. (Answer Questions at 6A) I do not know the identity of the biological father. (Answer Questions at 6B) I am UNWILLING to identify the biological father. (Answer Questions at 6C) (6A) If I know and am identifying the father: The name of biological father is __________________________________. His last known home address is ________________________________________________________________. His last known work address is ________________________________________________________________. He is ____________ years of age. I (Select one.) am married to the biological father within 300 days of the child's birth. am not and have not been married to the biological father

No order has been entered by any court finding the person I have identified as the biological father to be the father of my child, except in case number ____________________ in the Circuit Court located in _____________________

________________________ in the State of ________________________.
-ORI have no knowledge of any court or other proceedings brought by the person I have identified as the biological father of my child, except as follows: (Give details about the case.)

________________________________________________________________________________________________ _______________________________________________________________________________________________
Is this person listed on the child's birth certificate? Yes No Has this person registered with the Putative Father Registry? Yes No Has this person made any payments toward the expenses relating to the birth of the child? Has this person made any payments toward the support of the child? Yes No Has this person lived with the child? Yes No Has this person lived with you since the birth of the child? Yes No

Yes

No

(OVER)

(Rev. 2/21/08) CCCO 0032 B Has this person visited the child? Yes No Has this person communicated with you, the child or the agency having custody of the child since the child was born? Yes No If your answer to any of these questions was yes please explain. (Use additional sheet if necessary.) ________________

________________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________.
OR He is deceased, having died on __________________________, __________, at ____________________________
(Date)

_____________________________, in the State of ___________________.
(6B) If I do not know the identity of the biological father: I do not know who the biological father is and the following is an explanation of why I am unable to identify him: _______________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________.
(6C) If I am unwilling to identify the biological father: I do not wish to name the biological father of the child for the following reasons: ________________________________________________________________________________

___________________________________________________________________________________________ ___________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________.
(7) The physical description of the biological father is:___________________________________________________

_______________________________________________________________________________________________ _______________________________________________________________________________________________.
(8) I reaffirm that the information contained in paragraphs 5, 6 and 7, inclusive, is true and correct. (9) I have been informed and understand that if I am unwilling, refuse to identify, or missidentify the biological father of the child, absent fraud or duress, I am permanently barred from attacking the proceedings for the adoption of the child at any time after I sign a final and irrevocable consent to adoption or surrender for purposes of adoption. (10) I have read this Affidavit and have had the opportunity to review and question it; it was explained to me by

________________________________; and I am signing it as my free and voluntary act and understand the contents
and the results of signing it. Dated: __________________________, __________.

______________________________________________
Signature

Under penalties as provided by law under Section 1-109 of the Code of Civil Procedure (735 ILCS 5/1-109), I hereby certify that the statements set forth in this instrument are true and correct.

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