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:
Due or paid to:
Agency administrative expenses:B. Agency Mental Health Counseling expenses: 1. Counseling for adopting parents2. Home study evaluations3. Counseling for the childC. Medical expenses for biological mother: D. Medical/foster care expenses for child: 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, Louisiana 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 R.S. 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
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS _____ DAY OF ______, ___.