A.  Each petition for an adoption shall be accompanied by an affidavit executed by the petitioner and petitioner’s attorney containing an accounting of fees and charges paid or agreed to be paid by or on behalf of the petitioner in connection with the adoption.

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 paid to any agency or individual:

Actual

Estimated due:

Due or paid to:

$

$

A.  Agency administrative expenses:

1.  Attorney fees

2.  Court costs

3.  Travel costs

4.  Overhead

5.  Other (Specify)

B.  Agency Mental Health Counseling expenses:

1.  Counseling for adoptive parents

2.  Home study evaluations

3.  Counseling for the child

4.  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.  Other expenses (Specify):

(2)  We certify that to the best of our knowledge 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 office of adoption services, 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.

__________________________

____________________________

Signature of Petitioner

Signature of Attorney

_______________________________________________________________

Address

Address

SWORN TO AND SUBSCRIBED BEFORE ME ON THIS ____ DAY OF _____.

____________________________

(NOTARY PUBLIC)”

D.  Confidentiality of information contained in the adoption disclosure affidavit shall be maintained as provided in Chapter 5 of Title XII of this Code, 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 2013, No. 86, §1.