Free CCCO 0058 10-22-07.pmd - Illinois

Affidavit in Support of Petition to Adopt IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION COAD ____________________________________

(10/22/07) CCCO 0058 A

Case No. _______________________________

AFFIDAVIT IN SUPPORT OF PETITION TO ADOPT (2800)
I, __________________________________________, in support of my petition to adopt ___________________

_______________________________ do submit the following information to the Court for investigation and review.
1. My date of birth is ___________________________________, age: ____________. No If yes, please state those names and the date(s) and

2. Have you ever been known by another name? Yes reason for the change of name on a separate sheet of paper. 3.

My present address is: _______________________________________________________________________.

I have lived there since _______________. (If less than 5 years please state the address and dates of residence during that time on a separate sheet of paper). 4. 5. 6. 7. My home telephone number is _______________________. My work number is _______________________. My Social Security Number is ________________________. I am married separated; date of separation _______________________. not married.

The date and place of my marriage was ___________________________________________________________________.

8. I have have not been previously married. (If you been married before, on a separate sheet of paper, state the date of the marriage, the reason (divorce, death of a spouse) and exact date that the marriage ended. Note, you are required to furnish the investigator with documentary proof that any prior marriage has ended. 8a. I am currently employed by ____________________________________ which is located at ____________

________________________________________________________. My occupation is ______________________.
My gross pay is $ ______________________. I have been employed for ___________ years. (If less than 5 years, on a separate sheet of paper, list your place of employment during that time.) 8b. I am not currently employed. My current source(s) of income is (are) _________________________________

from which I derive an annual gross income of $ ____________________. 8c. I am retired after working ___________ years for ____________________________________________ as

a(n) ____________________________. My retirement income from all sources is $ ___________________ per year. 9. I have not have (choose one) been arrested and charged with a criminal offense other than a traffic violation punishable by fine only. (If your answer is yes, on a separate sheet of paper, list every incident for which you were arrested, the charge, describe your involvement, the date of arrest and the court disposition.) (OVER)

(10/22/07) CCCO 0058 B

10. I have not have (choose one) been advised that the Department of Children and Family Services has made an "indicated" finding for abuse or neglect of a child residing in the same household where I lived. (If your answer is yes, on a separate sheet of paper, please list the date of every incident, the allegation, whether you were required to attend court and the disposition.) 11. I am not am (choose one) required to register as a sex offender.

12. The names and ages of the child(ren) being adopted are: _________________________________________

________________________________________________________________________________________________________.
13. I am am not related biologically or by marriage to the child(ren) being adopted as their ____________

_____________________________.
14. I
their

am

am not related biologically or by marriage to a biological parent of the child(ren) being adopted as

_________________________________________.
have have not resided in my home. If yes. How long? _________________.

15. The child(ren) sought to be adopted 16. My religious belief is

________________________________________.

17. The child(ren)'s religious belief is

___________________________________________________________.

Under penalties of perjury and/or contempt of court, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true.

Signed:

______________________________________ ___________________________________

Print Name: Date:

____________________________, ___________

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