Adoption Disclosure Statement
This form is to be used in drafting an Adoption Disclosure Statement in the State of Oregon.Download
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THIS FORM IS AVAILABLE IN ALTERNATE FORMAT UPON REQUEST Policy Ref.: I-G.4 CF 960 (4/02) Distribution: Original to Court Copy to Attorney/Petitioner Copy to Department of Human Services -Adoption Adoption Disclosure Statement COURT CASE NUMBER: ADOPTION NUMBER: In the matter of adoption of Adoptee(s) Name by Petitioner(s) Name 1. We report the following fees and charges, or other considerations in connection with this adoption. ESTIMATED TOTAL PAID TO: A. Court Filing Fees: $ B. Petitioner’s Attorney Fees: (Total) C. Adoption Agency Fees / Contribution: D. Medical Costs Child: E: Birth Mother’s Expenses Attorney Fee: Counseling Fees: Room and Board: Travel: Other: F. Vital Statistics Fees: G. Other (Specify Below): ESTIMATED TOTAL: $ 2. We certify that no other fees, costs, or expenses have been paid or exchanged or shall be paid or exchanged by any party in this adoption proceeding. 3. We declare that this disclosure statement has been examined by me/us and that its contents are true to the best of my/our information, knowledge, and belief. Attorney Signature Bar No. Petitioner Signature Date Address Petitioner Signature Date DateRelevant article from our knowledge database
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