Adoption Information Form

ADOPTION INFORMATION FORM

This Adoption Information Form is submitted by the individual named below to document information relevant to a pending or prospective adoptive placement. The information provided will be used by the agency or authorized placement entity for assessment, home study, and placement purposes. Applicant(s) must answer all questions truthfully and completely. Intentional misrepresentation may result in termination of services or placement.

Applicant Information — Primary

Date of Birth:    Place of Birth (City, State):

Phone:    Email:

Co-Applicant / Other Adult Resident (If applicable)

Date of Birth:    Relationship to Primary Applicant:

Household Composition

Adoption Preferences and History

Employment and Financial Information

Combined Annual Income: $

Health, Background and Safety

Have you or any adult household member ever been convicted of a felony or a crime against a child? Yes No

References

Home Study and Agency Information

Has a home study been completed? Yes No

Authorization, Certification and Release

By checking the acknowledgment box below and signing this form, the Applicant certifies under penalty of perjury that all information provided in this form is true, complete, and correct to the best of the Applicant's knowledge. Applicant authorizes the agency, authorized placement entity, and their agents to verify any information provided herein including but not limited to employment, education, criminal history, child welfare records, medical records, and references. Applicant releases such entities from liability for good faith inquiries and verifications.

I hereby authorize verification and attest that the information supplied is accurate and complete.

Confidentiality and Use of Information

The information provided on this form is confidential and will be used solely for the purpose of evaluating suitability for adoption and for services related to adoption placement. Information will be shared only with authorized personnel, licensing or judicial authorities when required by law, and with placement parties as necessary to effectuate an adoption. Applicant understands that certain records and background information may be retained in agency files in accordance with record retention policies and applicable law.

Governing Law and Entire Agreement

This form and any authorization hereunder shall be governed by the laws of the state indicated by the Applicant below. This document constitutes the Applicant's written statement of information and the parties' rights and obligations hereunder, and it constitutes the entire agreement between the Applicant and the agency with respect to the information provided on this form.

Certification

I certify under penalty of perjury under the laws of the state indicated above that the foregoing is true and correct. I understand that falsification of this document may result in denial of services and may be subject to criminal penalties.

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