Surrogacy Agreement Questionnaire

SURROGACY AGREEMENT QUESTIONNAIRE

This Surrogacy Agreement Questionnaire is submitted for the purpose of collecting material facts to be incorporated into a surrogacy agreement and related legal documents. Intended Parent(s) Name: ; Intended Parent(s) Address: ; Surrogate Name: ; Surrogate Address: .

RECITALS

WHEREAS, the Intended Parent(s) desire to obtain assisted reproductive services resulting in the birth of a child and have engaged medical and legal counsel to prepare definitive contractual arrangements; and

WHEREAS, the Surrogate has expressed willingness to undergo medical procedures and to bear a child for the Intended Parent(s) in accordance with mutually agreed medical, legal, and counseling protocols; and

WHEREAS, the parties intend that the information provided in this questionnaire be relied upon by counsel and medical providers in drafting the Surrogacy Agreement and obtaining necessary medical clearances and legal orders.

NOW, THEREFORE

The parties hereby provide the following facts, acknowledgments, and authorizations for use in the preparation of a surrogacy agreement and related documents. The statements below are made under penalty of perjury to the best of the declarant's knowledge.

1. IDENTIFYING INFORMATION

2. SURROGATE MEDICAL AND OBSTETRIC HISTORY

Number of prior pregnancies: ; Number of live births: ; Number of miscarriages: ; Number of cesarean deliveries: .

Current medications (prescription and over-the-counter):

3. REPRODUCTIVE AND FERTILITY HISTORY

Has the Surrogate undergone fertility treatment (IVF, IUI, medications)? Yes No. If yes, describe:

Intended Parent(s) use of donor gametes or donor embryos: Yes No. If yes, specify donor type and known information:

4. PSYCHOLOGICAL, SOCIAL, AND LIFESTYLE INFORMATION

Does the Surrogate smoke, use recreational drugs, or consume more than moderate alcohol? Yes No. If yes, provide details:

Employment status and occupational exposures:

5. LEGAL, CRIMINAL, AND CHILD-RELATED HISTORY

Has the Surrogate or any Intended Parent been convicted of a felony or a crime involving moral turpitude? Yes No. If yes, provide jurisdiction, offense, and disposition:

Are there any pending child support, custody, or termination of parental rights proceedings involving any party? Yes No. If yes, describe:

6. INSURANCE, FINANCIAL ARRANGEMENTS, AND BENEFITS

Will the Surrogate retain any parenting rights or seek custody after birth? Yes No.

7. AUTHORIZATIONS, CONSENTS, AND BACKGROUND CHECKS

The undersigned authorizes medical providers, counselors, and legal representatives to disclose medical, psychological, and counseling records to the parties' counsel and treating providers as necessary to evaluate suitability for surrogacy. Check to authorize: .

I authorize submission to a criminal background check and child protective services records search where permitted by law: .

I understand that medical and psychological screening, insurance verification, and legal clearances are conditions precedent to the execution of any surrogacy agreement. The parties agree to cooperate in good faith to complete such screening in a timely manner.

8. COUNSELING, SUPPORT, AND POST-BIRTH ARRANGEMENTS

9. REPRESENTATIONS, WARRANTIES AND CERTIFICATIONS

Each party represents and warrants that the information supplied in this questionnaire is true, complete, and correct to the best of that party's knowledge and that any material change in health, legal status, or circumstances will be promptly disclosed in writing. Each party further acknowledges that the questionnaire will be relied upon by counsel and health care providers in drafting binding agreements and obtaining legal relief associated with parentage.

The parties understand and agree that completion of this questionnaire does not itself create any contractual parental rights or duties; those will be established only by the execution of a definitive surrogacy agreement and any necessary court orders.

10. NOTICES

All notices required or permitted hereunder shall be in writing and delivered to the addresses provided in Section 1 or to such other addresses as a party may designate in writing. Notice is effective upon personal delivery, delivery by nationally recognized overnight carrier, or three business days after deposit in the U.S. mail postage prepaid.

11. AMENDMENTS AND WAIVER

This questionnaire may be amended only by a written instrument signed by the party to be charged. No waiver of any provision will be effective unless in writing and signed by the party waiving the provision.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

Governing Law: The substantive law of the state or jurisdiction selected by the parties for the definitive surrogacy agreement will govern any dispute arising from reliance on this questionnaire or its contents, excluding conflict of law rules that would apply another jurisdiction's law.

Entire Agreement: This questionnaire constitutes the complete written statement of the information supplied herein and supersedes any prior written or oral statements for the purpose of drafting legal and medical documents related to the contemplated surrogacy.

Severability: If any provision of this questionnaire is determined to be invalid or unenforceable, such invalidity will not affect the remaining provisions, which will continue in full force and effect.

13. CERTIFICATION

By signing below, each party certifies under penalty of perjury that the statements in this questionnaire are true, accurate, and complete to the best of that party's knowledge. Each party authorizes counsel and medical providers to rely upon these statements in taking steps to prepare, negotiate, and finalize a binding surrogacy agreement and to obtain necessary court orders relating to parentage and custody.

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