Free CCO-0601 - Illinois

(Rev. 3/27/01) CCCO 0601 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT - COUNTY DIVISION IN THE MATTER OF THE PETITION OF

________________________________________________________
AND ___________________________________________________ TO ADOPT

________________________________________________________

AFFIDAVIT OF BIOLOGICAL PARENT*
I, ____________________________________________, am the ________________________________________________
(relationship)

}

No. _______________________________

______________________________________________________________________________________________, a minor.
1. Give the name and address of the person or organization which made arrangements to place your child with adopting parents and how you heard of that person or organization:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
2. I have received or have been promised the following contributions, compensation, money reimbursement, gifts, or other things of value FROM WHOM AND REASONS FOR PAYMENTS AMOUNT $ _______________________________

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________
3. I have paid and expect to pay: NAME Hospital _______________________________________________________ Obstetrician ____________________________________________________ Medicine _______________________________________________________ Other Medical Expenses __________________________________________

_______________________________ _______________________________ _______________________________ _______________________________
AMOUNT $ _______________________________

_______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________
(Name)

_______________________________________________________________
Other Expenses (Specify) __________________________________________

_______________________________________________________________ _______________________________________________________________
*Each parent must complete a separate Affidavit. Affidavit not to be completed in case of agency placement.

________________________________________________
(OVER)

(Rev. 3/27/01) CCCO 0601 B

CERTIFICATION
Under penalties as provided by law pursuant to Section 1-109 of the code of Civil Procedure, the undersigned certify 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