A. Each petition for an agency adoption shall be accompanied by an affidavit executed by the petitioner and petitioner’s attorney containing an accounting of all fees and charges paid or agreed to be paid by or on behalf of the petitioner in connection with the adoption. The affidavit shall include the date and amount of each payment made, the name and address of the recipient, and the purpose of each payment. Receipts, or other documentation in the event receipts are not available, for each expense shall be attached to the affidavit.

            B. The affidavit shall not include any identifying information as to the biological parents, their families, or the child‘s birth name.

            C. The form for the affidavit shall be as follows:

“ADOPTION DISCLOSURE AFFIDAVIT

            BEFORE ME, the undersigned authority, personally came and appeared __________ (petitioner) and _________ (attorney for petitioner), who being first duly sworn, did depose and state:

            In the matter of the adoption by ________ (petitioner’s name):

            1. We report the following fees and charges or other things of value given in connection with this adoption:

Itemization of Expenses Recipient Purpose Estimate Actual Date Paid

A. Agency administrative expenses:

            1. Attorney fees

            2. Court costs

            3. Travel costs

            4. Overhead

            5. Other (Specify)

B. Agency counseling expenses:

            1. Counseling for adopting parents

            2. Home study evaluations

            3. Counseling for biological parents

            4. Counseling for the child

            5. Statement of Family History information

            6. Other (Specify)

C. Medical expenses for biological mother:

            1. Medical

            2. Travel

            3. Other (Specify)

D. Medical/foster care expenses for child:

            1. Medical

            2. Travel

            3. Other (Specify)

E. Living expenses of the biological mother:

            1. Housing

            2. Utilities

            (a) Electricity

            (b) Gas

            (c) Water

            (d) Telephone

            3. Food

            4. Transportation

            5. Maternity clothing

            F. Living expenses paid to the biological mother during the term of the pregnancy by another agency or attorney:

G. Other expenses (Specify):

Total Estimated Total Paid

            2. We certify that no other fees, charges, or things of value other than court costs have been given or shall be given by anyone in connection with this adoption.

            3. We declare that this disclosure statement has been examined by each of us and that its contents are true to the best of our information, knowledge, and belief.

            4. We understand that each of us has a continuing obligation to supplement and amend this affidavit as necessary.

            5. We understand that this information will be transmitted to the Department of Children and Family Services. We further understand that it may be released by written authorization of the court for purposes of a grand jury investigation pursuant to La. Rev. Stat. 14:286 or for an ethical investigation by the Committee on Professional Responsibility of the Louisiana State Bar Association. We further certify that we understand that in accordance with La. Rev. Stat. 14:286, making a false statement in any adoption disclosure affidavit with the intent to deceive and with knowledge that the statement is false is punishable by a fine not to exceed fifty thousand dollars or imprisonment with or without hard labor for not more than ten years, or both.

            _____________________                                        _________________________

            Signature of Petitioner                                            Signature of Attorney

            ______________________                         _________________________

Address Address

            SWORN TO AND SUBSCRIBED BEFORE ME ON THIS _____ DAY OF ______, ___.

__________________________

                                                                        (NOTARY PUBLIC)”

            D. The adoption disclosure affidavit shall not be included as an exhibit for service with a copy of the petition under Article 1202.

            E. Confidentiality of the information contained in the adoption disclosure affidavit shall be maintained as provided in Chapter 5 of this Title, and shall be released only in accordance with this Article or on written authorization of the court for the purposes of a grand jury investigation of a violation of La. Rev. Stat. 14:286 or an ethical investigation by the Committee on Professional Responsibility of the Louisiana State Bar Association.

            Acts 1991, No. 235, §12, eff. Jan. 1, 1992; Acts 1993, No. 634, §1, eff. June 15, 1993; Acts 1999, No. 1062, §4, eff. Jan. 1, 2000; Acts 2018, No. 562, §1.