Ministry of Family, Youth, and Sports of Ukraine, The State Department for Adoption and Protection of Rights of the Child Adress: 14 Desyatynna Street, Kyiv 01025, Ukraine, From:---------------------------------- Citizen of the United States of America Passport No. --------------------- Issued by Passport Agency Washington, D.C. -------------------------------------- ------------------------------------- U.S.A. HOME ADRESS_______________________________ _____________________________________________ Home Phone: ---------------------- From:--------------------------------- Citizen of the United States of America Passport No. ------------------- Issued by Passport Agency Washington, D.C. ------------------------------------------ ------------------------------------------ U.S.A. HOME ADRESS_______________________________ _____________________________________________ Home Phone: ---------------------- FAX: ------------------------------ LETTER OF OBLIGATION We, _________________, and __________________, obligate to register any children adopted by us from Ukraine at the Ukrainian Embassy or Consulate in the United States of America within one month after the adoption is completed. The children will be registered at the Ukrainian Embassy located at 3350 M Street N.W., Washington, D.C. 20007 Also, we promise that we will inform the Ukrainian Embassy or Ukrainian Council no less than once a year about the physical and psychological development, as well as health and educational status of any children adopted from Ukraine. We also agree to allow Ukrainian officials, during any trips to the United States, to visit any children adopted by us from Ukraine. We also agree that any children adopted by us from Ukraine will keep Ukrainian citizenship until they reach 18 years of age. _________ ________ Signature (date) _________ _______ Signature (date) State of ---------, County of ---------- Sworn to and subscribed before me on this ______ day of ______________, 200__. ===================================================================================================== / Certified Notarially / My commission expires: _____________ Date: _____________ Signature: __________________ ________________________________________ ------------------, Notary Public Address:------------------------------------ -------------------- STAMP