Benefit Request

(To be submitted after adoption is finalized)

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 $10,000 per adoption.

Section 1

Item Description Amount
Adoption Agency Fees
$
Application Fees
$
Attorney Fees
$
Birth Certificates
$
Birth Mother Medical Care
$
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
$
$
$
$
$
$
$
$
$
$
$