Benefit Request (To be submitted after adoption is finalized) Name of Parents * CAA Membership # * Date of Adoption * Child's Birth Date * Child's Name * Itemized list of expenses You may not have amounts for all these items, or you may have some that are not on the list. Fill in what applies to your particular adoption. Current benefits are your actual adoption expenses up to $15,000. Section 1 Item Description Amount Adoption Agency Fees $ Application Fees $ Attorney Fees $ Birth Certificates $ Birth Mother Medical Care $ Courier Costs (Fed-Ex, etc.) $ Court Costs $ Fax Costs $ Finalization Costs $ Finger Prints $ Foster Care $ Section 2 Item Description Amount Home Study $ Immigration Papers $ Medical Exams $ Notary Charges $ Passports $ Postage (Mail, Fed-Ex, etc) $ Post Placement Visits $ Secretary of State Fees $ Translating $ Visas $ Section 3 Other (please list) Amount Other Item 1 $ Other Item 2 $ Other Item 3 $ Other Item 4 $ Other Item 5 $ Other Item 6 $ Other Item 7 $ Other Item 8 $ Other Item 9 $ Other Item 10 $ Total Cost $ If you are human, leave this field blank. Submit