4291 form-2026

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The document is an 'Adoption Placement Fee Disclosure Statement' required by the New York State Office of Children and Family Services for agency and private adoptions. It mandates a detailed disclosure of all fees associated with the adoption process, including medical, legal, and other necessary expenses. The form must be completed accurately to facilitate the review and approval of an Interstate Compact on the Placement of Children (ICPC) request. Unauthorized out-of-state agencies are prohibited from charging placement fees, while specific allowable fees are outlined. Additionally, it includes an affirmation section for attesting to the truthfulness of the disclosed information.

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Click ‘Get Form’ to open the 4291 form in the editor.
Begin by filling out the 'Category of Expenses' section. Enter the actual or estimated amounts for each fee, specifying the entity or person to whom payment was made.
Complete the 'Home Study' section by detailing any fees associated with the home study process, including write-ups and updates.
In the 'Medical' section, provide information on medical fees related to prenatal care and birth, including hospital charges and nursing fees.
Fill out the 'Legal' section with reasonable legal fees charged for services rendered during the adoption process. Ensure you include names and addresses of attorneys involved.
Describe any other fees in the designated area, ensuring all payments made or to be made are disclosed accurately.
Finally, complete the 'Circumstances of Placement' narrative, detailing how birth parents and adoptive parents became aware of each other.

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