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Affidavit of Agency CCCO 0009 - Illinois
| Affidavit of Agency Form. This is a Illinois form and can be used in County Division Cook Local County . |
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Print Form Clear Form 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 $ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ 0.00 $ ______________________ _________________________________________________________________ Other Expenses (Specify) ____________________________________________ TOTAL 2. 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
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