Ministry of Ukraine for Family, Youth, and Sports The State Department of Adoption and Protection of the 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 We promise that any children adopted by us from Ukraine will keep Ukrainian citizenship until they reach 18 years of age. Also, we promise that we will inform the Ukrainian Embassy or Ukrainian Consulate no less than once a year during first three years after adoption and then once in three years till the children turn 18 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 or representatives of the Ukrainian Embassy or Consulate to contact and visit any children adopted by us from Ukraine. We also promise to inform the Ukrainian Embassy or Ukrainian Consulate about the address change of adopted children. _________ ________ 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