ENCLOSURE (3) TO COMDTINST 1754.9A
REVERSE OF CG-5553A (10-92)
4. The following expenses were incurred (documentation
attached):
a. $ ________Public and private agency fees.
b. $ ________Placement fees, including fees charged adoptive parents for counseling.
c. $ ________Legal fees, including court costs.
d. $ ________Medical expenses, including hospital expenses for the newborn infant, for medical
care furnished the adoptive child before the adoption, and for physical examinations
of the biological mother of the child to be adopted.
e. $ ________Subtotal of Expenses Listed above (Items 4 a.
through 4 d.).
f. $ ________Amount of reimbursement previously applied for and/or received under any other
adoption benefits program administered by the Federal Government or under any
such program administered by a state or local government.
g. $ ________Total Expenses (Subtotal in (e) minus any reimbursements in (f)).
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