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Affidavit of Biological Parent CCCO-0601 - Illinois
| Affidavit of Biological Parent Form. This is a Illinois form and can be used in County Division Cook Local County . |
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(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 Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form
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