IVF Agreement and Statement

I the undersigned, _______________ (the woman), I.D. number ____________, hereinafter to be known as “___________,” and _______________ (the man), I.D. number ____________, hereinafter to be known as “___________,” of our free will, after having been cautioned per law that we must state the truth and that otherwise we shall be liable to the penalties established in the law, hereby state and stipulate the following:

1. We hereby proffer this Statement for the purpose of submitting it to the In Vitro Fertilization Unit at ________ Hospital (hereinafter: the “In Vitro Fertilization Unit”) in order to begin in vitro fertilization (IVF) or insemination treatment.

2. We hereby stipulate that with mutual consent and willing free choice and without any pecuniary consideration from any party whatsoever, we have applied to the In Vitro Fertilization Unit in order to perform in vitro fertilization from the semen of the man and the ova of the woman.

3. ____________ states that he is interested in having ____________ be fertilized with his semen, agrees that this should be done, and affirms his awareness that his obligations to the child shall be in effect irrespective of the validity of this Agreement and shall apply to him in any event, as a biological parent.

4. ____________ states that she is not a surrogate mother as this term is defined in the Consent to Surrogate Motherhood (Certification of Agreement and Status of Child) Law, 5757-1996.

5. ____________ and ____________ state that they are not married to other spouses.

6. Additionally, we state that we know and understand that upon the birth of the baby pursuant to this fertilization procedure, all obligations and rights flowing from natural biological parentage shall apply to us even if we are not married to each other at the time birth is given.

7. Provided that no law states to the contrary, upon the death of one of the Parties to this Agreement, their shared genetic material shall become / shall not become the absolute property of the surviving Party and s/he may do with it what s/he wishes.

8. Each of the Parties may at any time, by presentation of written demand, enjoin the In Vitro Fertilization Unit from making any use whatsoever of the shared genetic material. / The Parties hereby advise the In Vitro Fertilization Unit that they may neither disavow this Agreement nor demand that the In Vitro Fertilization Unit not make use of the shared genetic material and, by so stating, the Parties leave the decision on using the shared genetic material to the other Party.

9. ____________ and ____________ state that this Agreement was not executed in return for pecuniary or other consideration to any of the Parties thereto.

In witness whereof, we affix our signatures in Tel Aviv: