Affidavit {18.P4}

ePC-A-18.P4 (Rev. 01-2004) PROBATE COURT OF FRANKLIN COUNTY, OHIO ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OF THE PLACEMENT OF CASE NO. BIRTH MOTHER AND BIRTH FATHER AT PLACEMENT: AFFIDAVIT The undersigned, having been duly sworn in open Court, being the birth parent(s) of the above-named child, state(s) that the identity of the adopting parents are unknown to me/us, or my/our knowledge is limited to: I/we acquired knowledge by way of: Further, it is understood that I/we cannot require the adopting parents to provide me/us with letters, pictures, or any other means of communication against their will now or in the future and any agreements previously entered into regarding dissemination of information is not enforceable by the undersigned, the attorneys, or the adoptive parents. BIRTH MOTHER BIRTH FATHER Sworn to before me and subscribed in my presence this day of 20 . NOTARY PUBLIC / DEPUTY CLERK / MAGISTRATE FRANKLIN COUNTY FORM e18.P4 - AFFIDAVIT American LegalNet, Inc. www.FormsWorkFlow.com