FINANCIAL STATEMENT
INCOME
Wages/salary
Funds
borrowed/given
Benefits
(Welfare/DisabiIity/other)
Alimony/Child
Support
All
other income whatever the source,
in
cash or in kind
If
birthparent is claiming "zero” income
as
unemployed, what have been the sources of
support
for the past 2 months
EXPENSES
Unreimbursed/uncovered
medical
Rent/mortgage
Food
Utilities
Gas,
electric, oil, other
Car
payment
Car
insurance
Gas
(car)
Maintenance
Other
transportation (e.g.- bus)
Other
insurances:
Life
Health
Clothing
Maternity
clothing
Phone
Furnishings
Loans
Incidentals
Other related
expenses
Other
I
____________________________, under the pains and penalties of perjury, state
that the above accounting of my finances is a true and accurate report.
________________________________ ____________________
Name (sign
legibly please) Date
________________________________
Name (print)
EXAMPLES OF SUPPORTING DOCUMENTATION:
I Income
Employment - Pay stubs or employers note.
Alimony/ChiId Support - Copy of court order or copy of check.
Benefits - Copy of benefit assignment or check.
II Expenses
a. Regular Bills
Rent'/Mortgage - Copy of cancelled check or letter
from Landlord.
Electric/Gas/Oil - Copy of bill or cancelled check
Telephone - Copy of bill or cancelled check
Other monthly
bills - Copy of bill or cancelled check
b. Individual items
Food/clothing/incidentals - Actual receipts
Loans -
Copy of loan agreement and/or
cancelled check
Any questions feel free to call Toll Free
Full Cirde Adoptions Birthparent Line
Toll Free:
888-45-ADOPT
888-452-3678
STATEMENT OF
NO OBLIGATION RE: BIRTHPARENT EXPENSES
(Pursuant to
102 CMR 5.09)
You
have requested assistance in allowable expenses related to your maternity
period. Please be advised that payment for allowable living expenses (shelter,
food, clothing, pregnancy related travel, medical expenses) in no way obligates
you to place your child for adoption. If you have any questions, please discuss
them with your worker.
I
have read and understand the above. I have had an opportunity to fully answer
any questions I may have. I have received a copy of this statement.
________________________________ _____________________
Name Date
________________________________
Witness