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Adoption Disclosure Statement

This form is to be used in drafting an Adoption Disclosure Statement in the State of Oregon.Download

Extracted Text for Proper Search

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
Date
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