Adoption Affidavit of Agency Itemized Expenses

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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            No. 	______________________________
__________________________________________________	
TO ADOPT:
__________________________________________________	
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          AMOUNT
Hospital 	
__________________________________________________________	$	______________________	
Obstetrician 	______________________________________________ ______________________________	
Pediatrician 	____________________________________________ ________________________________	
Other Medical Expenses 	_____________________________________________ ______________________
_________________________________________________________________ ______________________	
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          AMOUNT
Hospital 	
________________________________________________________	 $	__________________________	
Obstetrician	____________________________________________________ _ __________________________	
Pediatrician 	___________________________________________ ___________________________________	
Other Medical Expenses 	___________________________________________ __________________________
_______________________________________________________________ __________________________
_______________________________________________________________ __________________________	
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