Fill and Sign the Adoption Expenses California Form

ADOPT- 230 If you are adopting your stepchild do not fill out this form. Your name(s) (adopting parent(s)): a. ––––– b. ––––– Relationship to child: ––––– Your address (skip this if you have a lawyer): Street: ––––– City: ––––– State: ––––– Zip: ––––– Your phone #: ( ––––– ) ––––– Your lawyer (if you have one): (Name, address, phone #, and State Bar #): ––––– ––––– ––––– Payment Date a. Hospital b. Prenatal care c. Legal fees d. Adoption agency fee e. Transportation f. Adoption facilitator fees Judicial Council of California, Rev. January 1, 2007, Mandatory Form Family Code, § 8610 Adoption Expenses 17 ADOPT-230, Page 1 of 2 Adoption Expenses Clerk stamps below when form is filed. Court name and street address: Superior Court of California, County of ––––– ––––– ––––– ––––– ––––– Case Number: ––––– Name of child after adoption: ––––– $ ––––– ––––– $ ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– $ ––––– ––––– $ ––––– ––––– $ ––––– ––––– $ ––––– ––––– List services you received that were related to the adoption of the child listed in  Name and Address of Service Provider How Much Paid or Value of ServiceService1 2 3 el ectr onic form ã 2002 WWW.LawCA.co m L a w P u b l i s h e r s Your name(s): ––––– Case Number: ––––– Name and Address of Service Service Service Provider How Much Paid or Value of Service Payment Date g. Counseling fees ––––– ––––– $ ––––– ––––– h. Adoption service ––––– provider ––––– $ ––––– ––––– i. Pregnancy ––––– expenses ––––– $ ––––– ––––– j. Court filing fees and ––––– fingerprinting fees ––––– $ ––––– ––––– k. Other ––––– ––––– $ ––––– ––––– If you need more space, attach a sheet of paper and write "ADOPT-230 , Item 3 Payment for Services" at the top. Number of pages attached: ––––– I declare under penalty of perjury under the laws of the State of California that I have listed all payments (or anything of value) that I have paid or agreed to pay, or that were paid on my behalf, related to the child I want to adopt. I declare under penalty of perjury under the laws of the State of California that the information in this form is true and correct, which means that if I lie on this form, I am guilty of a crime. Date: ––––– ––––– Type or print your name Signature of Adopting Parent Date: ––––– ––––– Type or print your name Signature of Adopting Parent Rev. J an uar y 1, 20 07 Adoption Expenses A D O P T - 2 3 0 , P a g e 2 o f 24 el ectr onic form ã 2002 WWW.LawCA.co m L a w P u b l i s h e r s