Surrogacy Contract Agreement
Between and _________
THIS AGREEMENT is made
this _ day of ______ 2013, by and between (fathers name) and (mother’s
name) (hereinafter referred to as
"Genetic Father and Genetic Mother" or collectively as "Genetic
Parents") and ________________
(hereinafter referred to as "Embryo Carrier").
The Parties are aware that surrogate parenting
remains a new and unsettled area of law and that this Agreement may be held
unenforceable in whole or in part as against public policy. The parents intend to move to California due
to a job offer to the Genetic Father. The mother has shown proof that she
cannot carry an embryo to a viable pregnancy. The Embryo Carrier intends to
travel to California for Embryo transfer and Delivery. Therefore the
Intended parents and Embryo carrier agree to use California State Surrogacy
law.
I. Purpose and Intent
The sole purpose and intent of this Agreement is
to provide a means for (fathers name) Genetic Father, to fertilize in vitro an ovum
from his wife (mother’s name) , Genetic
Mother, for transfer and implantation into (surrogate name) , Embryo Carrier, who agrees to carry
the ovum/embryo to term and relinquish custody of the child born pursuant to
this Agreement to its Genetic Parents, (fathers name) and (mother’s
name) .
II. Representations
(fathers name)
and (mother’s name) represent that they are a married couple,
each over the age of eighteen years, who desire to enter into this Agreement(fathers
name) and (mother’s name) further represent that to the best of their
knowledge they are respectively capable of producing semen and an ovum(s) of
sufficient nature for in vitro fertilization and subsequent transfer into (surrogate
name) , Embryo Carrier.
(mother’s name) cannot
carry her own embryo as proved by miscarriages and inability to get pregnant
over the past __ years. (put any other reasoning for having a
Surrogate to prove to the courts why it is necessary).
(mother’s name) will go through the process of retrieving
eggs but if they are not viable then the couple will use donated eggs.
The Genetic Parent’s address is: _________________________________________
Phone number(s) to reach Genetic Parents: ______________________________
(surrogate name) represents that she is a divorced woman, over
the age of eighteen years, and that she desires to enter into this Agreement
for the reasons stated above and not for herself to become the parent of any
child conceived (fathers name) and (mother’s name) pursuant to this Agreement. (surrogate name) further represents that to the best of her
knowledge she is capable of carrying an implanted ovum/embryo to term.
The Embryo Carrier’s address is :
Phone
number(s) to reach Embryo Carrier: Cell phone
III Selection of
Physicians and Counselor.
A. Genetic
Parents and Embryo Carrier will jointly select physician(s) to examine Embryo
Carrier, order and review medical and blood tests for Genetic Parents, Embryo
Carrier, and perform IVF procedures (the "Responsible Physician").
The parties will select a doctor to do the review and perform the IVF
procedures.
B. The
overseeing responsible doctor will be Dr. ____ OB-GYN from Cedar City (clinic name,
city, state) . The parties have agreed
jointly to use a Midwife in addition to the OB. If at any time the Midwife
feels there is a risk to the baby Dr ____ with be the advising doctor. Otherwise the
midwife will deliver the baby either at the Intended parent’s home, in California
or in a birthing center. Whichever is
most appropriate and all parties are comfortable with at the time of delivery.
C. At any time that Genetic Parents are
advised it is appropriate, Genetic Parents and Embryo Carrier will jointly
select an infertility specialist to become the Responsible Doctor.
IV. Physical
Evaluations
A. Embryo Carrier will have a medical
examination, blood and other tests and psychological testing as determined by
Genetic Parents and their advisors. (surrogate
name) expressly waives the privilege of confidentiality and permits the release
of any reports or information obtained as a result of said examination/testing (fathers
name) and (mother’s name) . Embryo Carrier maintains
her confidentiality with the therapy sessions involved in the surrogacy.
B. Embryo Carrier’s Husband has not had, and
will not have any contact with the Embryo carrier and lives in another state
and will not interfere in these proceedings in any manner.
C. Genetic
Parents will have blood and STD tests as determined by the Responsible
Physician. (fathers name) and (mother’s
name) expressly waives the privilege of
confidentiality and permits the release of any reports or information obtained
as a result of said examination/testing to (Surrogate name).
V. Conditions.
All parties' obligations under this Agreement
(other than the obligation of Genetic Parents to reimburse Embryo Carrier for
expenses incurred) are conditioned on:
A. The approval or Genetic Parents and their
advisors of results of Embryo Carrier’s exams and tests.
B. The approval of Embryo Carrier and the
Responsible Physician of results of Genetic Parents STD tests.
VI. Medical
Instructions
A. (surrogate name) agrees to adhere to all medical instructions
given to her, including abstention from sexual intercourse as directed by the
IVF Physician. (surrogate name) agrees
to follow a transfer and prenatal medical examination schedule set by the
attending Physician and Midwife.
B. Embryo Carrier will not smoke, drink
alcoholic beverages, use illegal drugs, non-prescription medication or
prescription medication without approval of the Responsible Physician.
C. Embryo Carrier will undergo prenatal medical
exams as directed by the Responsible Physician, will submit to other medical
tests, and will take only drugs and vitamins recommended or prescribed by the
Responsible Physician. Which include
Herbalife Multivitamins, and nutrition shakes, which she already takes.
D. Embryo Carrier will do everything
reasonably appropriate for her good health and the good health of the fetus
during pregnancy.
E. Embryo Carrier will not engage in any
hazardous or inappropriate activity during the pregnancy.
F. Embryo
Carrier will not travel outside of Utah, Nevada, California for work only and
the Parent’s state if the Intended
parents request it after second trimester of pregnancy, except in the event of
extreme illness or death in the family (with doctors approval).
VII. IVF Procedures
It is the parties' intention to do the
following:
A. Try the number of cycles recommended by
the Responsible Physician, but stop at any time that the physician recommends
stopping
B. Transfer a maximum of 2 embryos per cycle for the first 2 cycles. If after the first 2
cycles there is not an implanted fetus there can be an increase to 3 embryos.
VIII. Early
Termination of Agreement
Before Embryo Carrier becomes pregnant, the
agreement may be terminated:
A. By Genetic Parents, if the Responsible
Physician's opinion is that Embryo Carrier will not become pregnant within 8 cycles.
B. By Genetic Parents, if the Responsible
Physician or counselor determines that Embryo Carrier is not a good candidate
for carrying out this agreement.
C. By Genetic Parents or Embryo Carrier, if
Embryo Carrier has not become pregnant after 8 cycles.
D. By Embryo Carrier, if the Responsible
Physician determines that Genetic Parents are not good candidates for carrying
out this agreement.
E. At the discretion of Genetic Parents or
Embryo Carrier.
In the event of early termination, Genetic
Parents will be responsible for Embryo Carrier's costs incurred up to date of
termination.
IX. Termination of
Pregnancy.
The parties recognize that Embryo Carrier has
the constitutional right to abort or not abort the pregnancy, however, the
parties intend the following:
A. Genetic Parents and Embryo Carrier agree
not to abort the pregnancy except to save the life of Embryo Carrier.
B. Genetic Parents and Embryo Carrier agree
not to selectively reduce the number of fetuses in the case of a multiple
pregnancy.
X. Birth
A. Location.
It is the intent of both parties that the Embryo
carrier will have a water birth for the delivery of the baby either at home or
at the Birthing center whichever is most appropriate at the time. OB, Dr. ___ ,
of (clinic name) , will oversee the pregnancy
and potential birth if the Embryo Carrier cannot make it to California in time
for the birth. It is the intention that the embryo carrier will travel to
California and stay in California at 32
weeks for Multiples and 36 weeks for a single baby, prior to delivery and
anytime that she is put on an expected long term bed rest that could lead to
delivery, at the expense of the Intended parents, with the ultimate intent to
deliver in California at a home birth at the Intended Parent’s home, with the
assistance of a midwife.
B. Notice of Birth.
Embryo Carrier will notify Genetic Parents as
soon as she goes into labor so that Genetic Parents can join her at the place
of birth. Genetic Parents intend to be present during the delivery.
C. Responsibility for
Child.
Genetic Parents shall be responsible for any
children born, whether healthy or not. Embryo Carrier waives the right to make
medical decisions regarding the child after birth.
D. Child Born with
Severe Birth Defects
If the child is born with birth defects so
serious that life sustaining equipment is required and physician recommends
that the child not be placed on such equipment or not be resuscitated, Genetic
Parents will make the decision. If Embryo Carrier disagrees then she will be
responsible for the child from that time, and Genetic Parents will have no
further responsibility.
E. Name.
Genetic Parents will name the child.
F. People Attending birth
The people that attend the birth are the choice of the Embryo
Carrier. It is her intent that the
Genetic Parents will attend the birth, midwife and her assistant’s, her doula,
and a birthing photographer.
XI.
Relinquishment/Adoption.
Embryo Carrier will relinquish physical custody
of the child to Genetic Parents upon birth. Embryo Carrier and Genetic Parents
will cooperate in all proceedings for adoption of the child by Genetic Parents.
XII. Paternity test.
Embryo Carrier, Embryo Carrier’s Husband and
Genetic Parents agree that the child will have paternity tests, if Genetic
Parents request.
XIII. After Birth
Contact.
A. Embryo
Carrier can see the child while in the hospital, but the child will be in the
care of Genetic Parents from birth forward.
B. After Genetic Parents take the child from
the hospital, Embryo Carrier. Genetic Parents will keep Embryo Carrier informed
by sending a picture and a letter about the child’s progress at least on an
annual basis. Embryo Carrier agrees that she will be reasonably available if
child has questions about his/her birth mother.
XIV. Counseling
A. Counseling Sessions
It is the parties' intention that Embryo Carrier
will attend at least 1 counseling sessions per month with the Responsible
Counselor in Utah during the pregnancy. It is also the parties' intention that
Embryo Carrier will attend more counseling sessions if:
(i) Embryo Carrier wants to attend the
sessions;
(ii) Genetic Parents want Embryo Carrier to
attend the sessions; or
(iii) Embryo
Carrier's attendance is strongly recommended by the Responsible Counselor.
Embryo Carrier will use her reasonable efforts
to attend the meetings, but will not be penalized for not attending if she does
not feel well.
B. Disagreements.
The parties intend that if they have
disagreements among them that they are unable to resolve quickly or if there
are issues that they want to bring up before a third party, that they will
discuss the disagreements or issues in a conference call or meeting under the
direction of the Responsible Counselor. The parties acknowledge that the
Responsible Counselor is very experienced in surrogacy matters and agree to be
guided by her recommendations.
XV. Fees, Reimbursement, Insurance, and Other Expenses
A. Embryo Carrier’s
Fee
1. Genetic Parents agree to pay Embryo
Carrier as compensation for services provided the sum of $____ . The
compensation shall be paid in 10 equal monthly installments, the first being
paid after the pregnancy is confirmed.
2. In the case of a multiple pregnancy,
Genetic Parents agree to pay Embryo Carrier a bonus fee of $4,000 per
additional child. Bonus fee will be added to the original fee of $______ and disbursed in equal monthly installments.
3. Escrow Account - Genetic Parents will open
an escrow account and will place all fees in the account before IVF procedures
begin. Genetic Parents’ attorney will be authorized to disburse funds from the
account per the payment schedule set out above (Section XV, Part A, Paragraph 1
and 2). All other Fee’s as described in
the remaining parts of this contract will be paid to the recipient of the fee
within 2 weeks of the Genetic carrier reporting the expense with receipt (for
reimbursement) or bill to the Genetic parents.
4. Embryo Carrier will receive the total fees
set out above (Section XV, Part A, Paragraph 1 and 2), provided she carries the
child(ren) at least 32 weeks for a single, 28
weeks if multiples.
5. In the event that a cesarean is ordered in
either a single or multiple birth, Embryo Carrier will be paid an additional $3000.
6. Genetic Parents will place $5,000 in the aforementioned escrow account (v) to
pay for any medical expenses not covered by insurance.
7. For a completed cycle that does not result
in a pregnancy, Embryo Carrier will be paid a sum of $1000.
8. Loss of any female reproductive organs is $5000 paid at
time of loss.
9.. Invasive
procedures (each procedure is separate, regardless if they are performed on the
same day) are to include amniocentesis (per sac), cerclage, CVS or ectopic
pregnancy with or without tubal removal, DNC undergoes or experiences a
miscarriage with a clinical abortion), HSG, SIS, selective reduction,
hysteroscopy, termination, abortion prior to 12 weeks are $750. As well as any Post-partum
Invasive procedures relating to the pregnancy and/or delivery are included up
to eight (8) weeks after delivery or termination of pregnancy.
B. Termination of
Pregnancy
1. If Embryo Carrier miscarries (through no
fault of her own) or is advised by by the Responsible Physician that an
abortion is necessary to save her own life, then the payment plan outlined in
Section XV, Part A, will cease and all payments to date will belong to Embryo
Carrier. Any outstanding uninsured or unreimbursed medical expenses will be the
responsibility of the Genetic Parents.
2. If Embryo Carrier aborts the pregnancy
when not directed to do so by the Responsible Physician and Genetic Parents,
Genetic Parents will have no responsibility for surrogacy fee or expenses other
than Embryo Carrier's expenses incurred to that date.
C. Insurance
1. Genetic
Parents will be responsible for term life insurance for Embryo Carrier
2. The policy will be bought before the first IVF cycle
and will remain in effect until 2 months after delivery or end of pregnancy. It
will cost approximately $500 premium for $500,000 face amount of insurance. The
beneficiaries will be Embryo Carrier's Children: (name beneficiaries) .
D. Counseling
1. Genetic Parents responsible for
costs of psychological screening for Embryo Carrier.
2. Genetic Parents responsible for costs of
counseling for Embryo Carrier.
3. Genetic Parents responsible for up to 5 counseling
sessions for Embryo Carrier with the Responsible Counselor after the birth, if
needed.
E. Medical Payments.
1. Genetic Parents responsible for the
reasonable costs of medical screening for Embryo Carrier, Genetic Mother and
Genetic Father.
2. Genetic Parents responsible for all
medical costs related to conception, pregnancy and birth not covered by medical
insurance. Including but not limited to,
Fertility specialists, specialized physicians, Hospital stays, medical testing,
Midwife, and chiropractic care.
3. If a medical specialist for high-risk
pregnancy is recommended by the Responsible Physician and not covered by
insurance, Genetic Parents will be responsible for all related costs.
F. Attorney's Fees.
Genetic Parents responsible for their Attorney’s
fee’s and the Embryo Carrier's attorney's fees for all proceedings regarding the Surrogacy
including but not limited to contract’s, mediation, adoption and litigation.
G. Other Payments
1. Reimbursement for child care expenses
related to Embryo Carrier's travels to doctor visits. ($10/hr or $75/day for
overnight care)
2. Reimbursement for gas and travel expenses
at $.45 per mile for car, airline tickets, and hotel in connection with doctor,
delivery, counseling visits or any other travel incurred due to the pregnancy.
3. Household helper: Genetic Parents will
provide $100 per week in the case of multiple
pregnancy or high-risk pregnancy in which the Responsible physician requires
Embryo Carrier to be on bed rest or drastically reduce her activity or
Housekeeping allowance of $50 every week beginning the 1st day of
the third trimester of pregnancy ending 4 weeks after delivery of a child.
4. Maternity clothing allowance of $500.00 is payable upon reaching 12 weeks
gestation. An additional $250 for multiples is allowed at 24 weeks gestation.
5. Stillborn
Genetic Parents will be responsible for any
funeral or cremation expenses.
6. Genetic Parents are not responsible for any
charges or costs unless provided for in this Agreement.
XVI. Other Issues
A.
Publicity/Confidentiality.
1. Embryo Carrier will not disclose
information about Genetic Parents or about this arrangement to the media unless
Genetic Parents approve the disclosure.
2. Genetic Parents will not disclose
information about Embryo Carrier or about this arrangement to the media unless
Embryo Carrier approves the disclosure.
3. Both parties advance agree to allowing each other to write
about their experience via twitter, Facebook, any social media site or any
public blogging site as long as the other party keeps the confidentiality of
the other party’s name and identifying information. Unless the other party
reveals themselves on that media as to whom they are. With the main intent of
allowing both parties friends and family to be able to be supportive, stay in
touch with and be educated on the entire process. All posts are to be positive in tone and
never allowed to be demeaning, negative or slanderous in manner.
B. Death of Genetic
Mother or Genetic Father Precedes Birth of Child(ren)
1. If Genetic Father should die before child
is born, the child shall be placed with Genetic Mother as the mother, and all
terms of this Agreement continue.
2. If Genetic Mother should die before child
is born, the child shall be placed with Genetic Father as the father, and all
terms of this Agreement continue.
3. If both Genetic Mother and Genetic Father
should die before child is born, they have chosen __________________ to be
child's guardian and take custody at birth.
4. In the event of the death of both Genetic
Mother and Genetic Father, ________________ will be responsible for all
expenses related to the surrogacy.
XVII. Arbitration
Any and all disputes relating to this Agreement
or breach thereof shall be settled by arbitration in by Utah State Court
Mediator Jodie Jones 146 N Stone Mountain Dr. St George UT 84770, Phone # (435)
632-3136 or (435) 628-3166 in accordance with then current rules of the
American Arbitration Association, and judgment upon the award entered by the
arbitrators may be entered in any Court having jurisdiction hereto. Costs of arbitration,
including reasonable attorney's to the prevailing party by the Party designated
by the Arbitrator or Court. Should one party either dismiss or abandon the
claim or counterclaim before hearing thereon, the other Party shall be deemed
the "Prevailing Party" pursuant to this Agreement. Should both
parties receive judgment or award on their respective claims, the party in
whose favor the larger judgment or award is rendered shall be deemed the
"Prevailing Party" pursuant to this Agreement.
XVIII. SIGNATURES
Successors & Assigns:
This agreement shall insure to the benefit of
and be binding on the parties, their heirs, personal representatives,
successors and assigns. IN WITNESS WHEREOF, the parties have executed this
agreement on the date first written above.
Dated this _____ day of _____, _____ at
_____________________, ________
____________________________________,
Embryo Carrier
By: (surrogate name)
NOTARY
State of _____________ County
of______________________________
I, ___________________________________,
a Notary Public of said County,
Do certify that the foregoing contract
was acknowledged before me on the
_____________day
of_____________________, 20____.
Given under my hand this
____________day of ______________, 20_____.
My commission expires:
_________________/__________________________________
Date Signature of
Notary Public
____________________________________, Genetic
Father
By: (fathers
name)
NOTARY
State of _____________ County
of______________________________
I, ___________________________________,
a Notary Public of said County,
Do certify that the foregoing contract
was acknowledged before me on the
_____________day
of_____________________, 20____.
Given under my hand this
____________day of ______________, 20_____.
My commission expires:
_________________/__________________________________
Date Signature of
Notary Public
____________________________________, Genetic
Mother
By:
(mother’s name)
NOTARY
State of _____________ County
of______________________________
I, ___________________________________,
a Notary Public of said County,
Do certify that the foregoing contract
was acknowledged before me on the
_____________day
of_____________________, 20____.
Given under my hand this
____________day of ______________, 20_____.
My commission expires:
_________________/__________________________________
Date Signature of Notary Public
