The 7 Page Application to Be Completed, Signed, and Returned to Us;

Potential Surrogate Mother:

Thank you for your interest in our program. If you have accessed this application from our web site, you should already have installed Adobe Acrobat Reader on your system. If you would like the brochure that we typically send to surrogates, please let us know, and we will send it to you. The following information should be printed out:

The 7 page application to be completed, signed, and returned to us;

a medical records release form to be sent to whichever doctor(s) delivered your child(ren). It more than one doctor was involved, make a copy of this and give it to each doctor who would have your pregnancy records. DO NOT RETURN THIS FORM TO US. SEND IT TO YOUR DOCTOR.

an autobiographical questionnaire about you, your family, your spouse, etc. This is a form prepared by our psychologist and both you and your husband (or significant other if you are living with someone) need to fill it out separately.

a criminal history release form to be delivered to your local law enforcement agency. DO NOT RETURN THIS FORM TO US. Take it or mail it to your local sheriff’s or police department.

Once I receive your application, I will review it and call you to go over it. I will also answer any questions you may have about the program. If you do not have a phone, you will need to call us from someone’s home a week after you’ve sent us the application. If you have not heard from us within a week, please contact us.

After the initial interview with me, I will draw up a profile sheet that summarizes the things the couples would want to know about you. That profile sheet is then shown to the couples that are looking for surrogates. Once a couple indicates that they are interested in working with you, I will call you and give you the same type of information about the couple that I given them about you. You can decide if they sound like the type of people for whom you’d like to do this. If so, we will send your application to our psychologist, and he will call you to go over it and schedule a time for you to come here for the full psychological testing.

Because we have such an active surrogate program, it is important that you return the application as soon as possible. Please review the checklist included with this packet to make sure you’ve done everything we’ve asked. If you have any questions about any of this, feel free to call.

Thank you again for your interest in our program. You are about to become involved in a wonderfully rewarding experience, and you will be providing the most valuable gift imaginable to people who desperately want a child. We look forward to hearing from you.

Very Truly Yours,

StevenC.Litz

SCL/tim

Enclosure

TO ALL SURROGATES REGARDING HEALTH INSURANCE

AND EXPENSE REIMBURSEMENT

Health Insurance

Because of some recent confusion over health insurance and how it applies to surrogacy, all potential applicants should read the following note carefully. Health insurance companies are in the business of making money. Pregnancy is expensive, and insurance companies do not like to pay for it. They like it even less in surrogate situations, but so long as their policies do not exempt surrogacy, they are legally obligated to pay for your pregnancy.

A few insurance companies have given us problems in this regard, so the first piece of advice is not to mention anything to your employer about the fact that you're thinking of being a surrogate. It's not that we're hiding anything from the insurance company; it's simply none of their business. If you became pregnant by your husband, they certainly wouldn't ask you who the father was, so why should that matter when the child is not his?

Secondly, and equally as important, if you currently have insurance you must use your own insurance to pay for your medical expenses. The reasons for this is that if you do not, then the couple would be required to take out a policy on you, and the application you would fill out would ask if you had insurance in force already. If you say that you do, then the new policy would apply only after the first one paid your bills. If you say that you don't, then you're lying and you'd be liable for fraud. So, if you do have insurance, but you do not want it to be used, DO NOT APPLY TO OUR PROGRAM.

Expense Reimbursement

As mentioned to you when you first called in, the couple pays for all of your travel expenses. They also will pay for your husband's travel when you come to Indianapolis to be screened psychologically, and when you travel to one of the cities for the initial screening for the AI or embryo transfer program (if you are involved with that program). For the actual inseminations and/or embryo transfers, your husband's presence is NOT required, and the couple will not pay for his travel. If you want him (or anyone else) to accompany you, that is fine, but it will be at your expense.

Also, while you are traveling, you get $100/day for your travel. This covers your meals, your and your husband's lost wages, and your childcare. These things are not reimbursed because requiring you to keep receipts and submit them to us was too much of a problem. So, you get a flat $100/day. So, for example, if you and your husband (if you are married) come here Friday night, and leave Sunday, you would be reimbursed $200.

Finally, should any of you wish to speak to other surrogates, we will be providing you with the names and phone numbers of dozens of women from across the country. Once you are accepted into the program, we will reimburse you for calls to any of these women, up to $10/month. Calls you make to your couple are always reimbursed, so long as they are not excessive (we had one surrogate who called her couple 25 times in one day).

StevenC.Litz, Attorney at Law

PO Box 216

Monrovia, IN 46157

(317) 996-2000

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Date:______

Name:______

Address: ______

______

TO WHOM IT MAY CONCERN:

This is to authorize you to release any and all medical records to the above-named attorney. The following information should assist you in locating my records:

Last 4 digits of your Social Security #: XXX-XX-______Date of Birth: ______, 19___

Date of Hospitalization______

or treatment

Reason for Treatment: ______

Physician (if known): ______

Please release all records concerning my hospitalization and/or treatment. The release of records is in no way related to the care I received, but is necessary for other legal purposes. Please send a bill to Mr.LitzBEFORE sending the records. He will send you a check once he needs the records. Please do not send the records and a bill together.

I understand that I may withdraw this release at any time, and if I do so, I will notify you in writing.

Very Truly Yours,

X______

NOTE: If you are married or have a significant other, both of you must complete this form. If you are single, only you must complete this form. PLEASE DO NOT SEND THE FORM BACK TO US. YOU NEED TO TAKE IT TO YOUR LOCAL SHERIFF’S DEPT., SO THEY CAN OBTAIN YOUR CRIMINAL HISTORY. THEY WILL SEND IT TO US.

AUTHORIZATION FOR RELEASE OF CRIMINAL HISTORY

I/We, ______and ______hereby authorize you to release to StevenC.Litz, Attorney at Law, PO Box 216, Monrovia, IN, 46157, any and all criminal history you may have on me/us. This includes all arrests whether or not they resulted in convictions. My social security number is ______. My spouse’s or significant other’s social security number is ______. My date of birth is ______. My spouse or significant other’s date of birth is ______.

I/We understand that we may revoke this release at any time, and if I/we do so, we will notify you in writing.

DATED this ______day of ______, 20___.

______

[Your Name][Spouse or Significant Other’s Name]

STATE OF ______)

) SS:

COUNTY OF ______)

Before me, a Notary Public, in and for said county and state, personally appeared ______and ______, who acknowledged the foregoing and stated that any representations therein were true and accurate to the best of her/their knowledge and belief.

Dated this ____ day of ______, 20____.

______

Notary Public

Resident of ______County

POTENTIAL SURROGATE MOTHER APPLICATION

Please complete, date, and sign this application. Failure to respond to portions of the questionnaire or false answers will automatically eliminate you from theprogram. Please read the enclosed information beforeanswering these questions. Thank you.

DS: _____/____/_____

DR: _____/____/_____

DI: _____/____/_____

[Check those that apply]

I am interested in being a surrogate:

___ only in the artificial insemination program;

___ only in the IVF/embryo transfer program;

___ only as an egg donor;

___ in any of the programs.

I will be a surrogate for:

______a couple;

______a single man;

______a gay couple or a gay single man;

______any of these

1. Name:______Husband's (or Partner’s) Name:______

Address:______Husband's birthdate:______

______Husband's SS#:______-______-______

County of Residence: ______

Phone:(_____)______-______(home) Your SS#:______-______-______

Email address: ______@______.______

2. Marital Status: ______Date of present marriage: ______

Date(s) of prior marriage(s) and divorce(s) for you and your husband: ______

______

If you are married, what was your maiden name? ______

3. Age: ____ Birthdate: ______Birthplace: ______Race: ___ Height: ____

Weight: ______Eyes: ___ Hair: ___ Blood Type: ___ Husband's Blood Type: ____

4. Occupation: ______Employer's Name, Address, and Phone Number:

______

Annual Income: Yours: $ ______Your Husband's: $______Husband's

Occupation and his employer: ______

5. Number of pregnancies: ______Number of children: ______

Names:______

Ages:______

Height:______

Weight:______

Eyes/Hair:______

Birth Wght ______

6. Education: Please list all schools attended and degrees received, beginning with high school.

Name of SchoolDates AttendedGraduated?Degree Rcvd

7. MEDICAL/SOCIAL HISTORY: Please answer the following questions to the best of your ability. If any questions are answered "yes," give a complete explanation on page 4.

Have you , your children, or anyone in your family

everhad any of the following:

Yes NoYes No

A. Seizures, fainting spells, paralysis, nervous or ______

mental disorders, dizziness, or any other

disorder of the heart or blood vessels?

B. Asthma, emphysema, shortness of breath, chronic ______

cough, or any other disorder of the lungs or U. Do you (or your husband) smoke cigarettes or have ______

done so within the past year?

C. Frequent or recurrent abdominal pain, bleeding from______

or disease of the stomach, intestines, gallbladder, or liver, V. Did you smoke while you were pregnant?______

indigestion, ulcers, diarrhea, or colitis?

W. Are you currently taking any prescribed medicines? ______

D . Sugar, protein, or blood in the urine; kidney ______

stone, or any other disorder of the kidneys,X. Have you ever been advised to limit your use of ______

bladder, or prostate? alcohol or other addictive substances?

E. Any disorder of the uterus or ovaries, any ______Y. Do you drink coffee?______

venereal disease, or any type of complications during

or as a result of pregnancy? Have you ever had a Z. Have you ever been treated for or told to seek ______

C-section, or any other difficult with pregnancy?treatment because of alcohol or drug abuse, or any

Have you ever had a miscarriage or stillbirth? other chemical dependency?

F. Diabetes, thyroid, or other glandular disorder? ______AA. Do you exercise? If so, how and how often?______

G. Arthritis,, bursitis, sciatica, gout, recurrent ______BB. Has any member of your immediate family ever had

back pain, or any disorder of the back, spine, diabetes, cancer, stroke, high blood pressure or any ______

muscles, bones, or joints? type of heart disease? If so, identify each person

so affected, the condition involved, and the current

H. Disorder of the eyes, ears, nose, or throat?______age or age at death.

I. Cyst, tumor, cancer, or blood disorder?______CC. Have either of your parents passed away? If so, ______

please list the cause and date of death on the next page.

J. Disorder of the skin, lymph system, or breasts? ______

DD. Have you, your husband, or any of your children ______

K. Any physical deformity or defect?______been charged with or convicted of any crime (other

than minor traffic offenses)?

L. Any disease not previously covered (other than ______

minor childhood diseases)? EE. Do you have or are you covered by medical ______

insurance? Does it cover pregnancy?

M. Have you or your husband (if married) ever had ______If so, please list the company and policy #.

marital problems? Have either of you ever seen a

psychologist or other mental health counselor? FF. Are you currently using any type of birth control, or ______

If so, when and why? have you ever had a tubal ligation, or has your

husband had a vasectomy? HAVE YOU USED DEPO-PROVERA

OR BEEN ON THE PILL IN THE PAST YEAR?

N. Do you want more children of your own? If so, ______

how many, and when would you like more?GG.Have you (or your husband, if married) ever ______

declared bankruptcy?

O. Do you own a major credit card? ______HH.Have you ever applied to any other surrogate program, or do you now______

What type is it? (We don’t need the #, just the. have an application pending with any other program?

type—Visa, MC, Disc…)

P. Have you ever had an abortion? ______II. Which best describes your cycles: _____ perfectly regular, like clockwork

_____ very regular, I know when I’m ovulating

_____ pretty regular, normally 28-30 days

Q. Had a check-up, consultation, illness, or surgery?______it varies, sometimes 28 days,

sometimes several days shorter or longer

R. Been treated or evaluated at a hospital, clinic or______I’m not sure what my cycle is like

other medical facility?

JJ.Have you ever used marijuana, cocaine, crank, or any other ______

S. Had an EKG, x-ray, or other diagnostic test? ______controlled substance? If so, when was the last time, how often did you use

respiratory system?it, and what drug did you use?

T. Been advised to have any medical test or surgery______KK.If you were to be given a urine screen today, would you______and not followed such advice? test negative? If not, what would you test positive for?

LL.Do you have any children who have ever lived with someone other______

than you? If so, please state who they are, where the lived and when, and the reason that they lived elsewhere.

PLEASE REMEMBER TO GIVE DETAILS OF ALL “YES” ANSWERS ON PAGE 4. IF YOU

NEED TO USE ADDITIONAL PAPER, FEEL FREE TO DO SO.

2

During the past MONTH, have you often been bothered by...

Yes No

1.stomach pain______

2.back pain______

3.pain in your arms, legs, knees, hips______

4.menstrual pain or problems______

5.pain or problems during intercourse______

6.headaches______

7.chest pain______

8.dizziness______

9.fainting spells______

10.feeling your heart pound or race______

11.shortness of breath______

12.constipation, loose______

bowels, or diarrhea

13.nausea, gas, or indigestion______

14.feeling tired or having low energy______

15.trouble sleeping______

16.the thought that you may______

have a serious undiagnosed disease

17.your eating being out of control______

18.little interest or pleasure in ______

doing things

19.feeling down, depressed, or______

hopeless

20.“nerves” or feeling anxious or on______

edge

21.worrying a lot about different ______

things
During the PAST MONTH…

Yes No

22.have you had an anxiety attack______

(suddenly feeling fear or panic)

23.have you thought you should cut______

down on your drinking of alcohol

24.has anyone complained about ______

your drinking

25.have you felt guilty about______

how much you drink

26.was there ever a single day in which______

you had 5 or more drinks of beer,

wine, or liquor

27.have you used marijuana______

or any other non-prescribed drug

Overall, would you say your health is:

Excellent_____

Very Good_____

Good_____

Fair_____

Poor_____

3

[Explanation of "Yes" answers on this page]

Question No. Answer

How long did it take you to become pregnant with each of your children?

When was your last menstrual period, and how long did it last? Note: if you are not on the pill or using Norplant, you will need to chart your temperature. You may go to to do this, or you may download a basal body temperature chart at the following site:

After you have completed one month of charting, make a copy of the chart, and send it to us.

Are you adopted, or do you know anyone who is? Have you ever placed a child for adoption?

What were your feelings during your prior pregnancy (pregnancies)?

Do you have any objections to abortion? _____ If so, would you still be willing to terminate a pregnancy if asked to do so? _____

Do you have a MySpace or Facebook page? _____ If so, please provide the web address for either or both:

4

8.REFERENCES: Please list the names, addresses, and phone numbers of three (3) people other than family members who have known you for at least 5 years. Please discuss your participation in our program with them, so that when we contact them, they will know why we're calling.

9.DOCTORS' NAMES: Please list the names, addresses, and phone numbers of your current physician, your children's physician, and any other doctor that would have the ability to provide copies of your medical history. IF YOU HAVE SEEN A MENTAL HEALTH COUNSELOR, YOU WILL NEED TO GET YOUR RECORDS FROM THAT PERSON.

NOTE: We will need your medical records from all of your previous pregnancies, if any, and any visits you or your husband may have made to a mental health counselor. Please contact your physician/OB and/or your counselor, and ask him/her to send us your records, or use the enclosed medical release form to obtain them. Do not send the medical release form back to us.

10.Explain why you wish to be a surrogate.

11.Indicate what (if anything) your fee would be to be a surrogate. Please do NOT put a range of fees in. List an exact figure. NOTE: If you are requesting additional money in the event of a multiple pregnancy, please indicate. Please note that you cannot request additional amounts per child. You can either request a single fee, or one fee for a single birth and a different fee for multiple births

$______(single birth)$______(multiple births)

12BE SURE TO INCLUDE 2 RECENT PICTURES OF YOURSELF AND YOUR CHILDREN (IF YOU HAVE ANY) WITH THIS APPLICATION.

Signature(s):______

ApplicantHusband (if married)

______

DateDate

5

AGREEMENT

By filling out the enclosed application, returning it to Surrogate Mothers, Inc. ("SMI"), and upon notification that a couple is interested in working with me, I (meaning both myself and my husband if I am married) agree that: