Legal Adoption Form

INDEPENDENT ADOPTION QUESTIONNAIRE

Child’s Name:

Child’s Adopted Name:

First Petitioner’s Name:

Second Petitioner’s Name:

FIRST PETITIONER’S INFORMATION

Last Name: First Name:

Middle Name:

Race: Gender: Religion:

Place of Birth: Birthdate:

Social Security Number:

Name and Address of Employer:

Occupation:

Work Hours: Length of Employment:

Monthly Salary: $ Work Telephone Number:

Are you a United States citizen? Yes No

Are you a permanent resident? Yes No

If naturalized: Date: Place: Number:

Date of arrival in U.S.: Alien registration number:

Military service: Yes No Date of service:

Date of discharge: Honorabale Honorable Dishonorable

Education (highest grade completed):

Driver License Number:

CRIMINAL HISTORY

1) Have you ever been arrested for an offense other than a traffic infraction? Yes No

If yes, please explain the charges and any convictions:

2) Are you currently on probation or parole? Yes No

If yes, please explain the circumstance:

3) Have you ever been investigated for allegations of child neglect or abuse? Yes No

If yes, please explain the circumstances:

4) Have you ever been reported for allegations of domestic violence? Yes No

If yes, please explain the circumstances and outcome:

5) Are you in good health? Yes No

If no, please explain:

6) Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information:

7) Do you have a history of alcohol or drug abuse? Yes No

If yes, please explain:

FORMER MARRIAGE(S)

Full name of former spouse: Marriage date:

Where (license issued in county/state): Divorce date & place:

Date of death (if deceased):

CHILD(REN)

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

1) Have any of your children ever been arrested for an offense other than a traffic infraction? Yes No

If yes, please explain the charges and any convictions:

2) Are any of your children currently on probation or parole? Yes No

If yes, please explain the circumstance:

3) Have any of your adult children ever been investigated for allegations of child neglect or abuse? Yes No

If yes, please explain the circumstances:

FAMILY HISTORY

Father: Mother: Sibling:

Sibling: Sibling:

SECOND PETITIONER’S INFORMATION

Last Name: First Name:

Middle Name:

Race: Gender: Religion:

Place of Birth: Birthdate:

Social Security Number:

Name and Address of Employer:

Occupation:

Work Hours: Length of Employment:

Monthly Salary: $

Work Telephone Number:

Are you a United States citizen? Yes No

Are you a permanent resident? Yes No

If naturalized: Date: Place: Number:

Date of arrival in U.S.: Alien registration number:

Military service: Yes No Date of service:

Date of discharge: Honorable Dishonorable

Education (highest grade completed):

Driver License Number:

CRIMINAL HISTORY

1) Have you ever been arrested for an offense other than a traffic infraction? Yes No

If yes, please explain the charges and any convictions:

2) Are you currently on probation or parole? Yes No

If yes, please explain the circumstance:

3) Have you ever been investigated for allegations of child neglect or abuse? Yes No

If yes, please explain the circumstances:

4) Have you ever been reported for allegations of domestic violence? Yes No

If yes, please explain the circumstances and outcome:

5) Are you in good health? Yes No

If no, please explain:

6) Explain all current and chronic illnesses, past and future surgeries, medications you are currently taking, and other relevant health information:

7) Do you have a history of alcohol or drug abuse? Yes No

If yes, please explain:

FORMER MARRIAGE(S)

Full name of former spouse: Marriage date:

Where (license issued in county/state): Divorce date & place:

Date of death (if deceased):

CHILD(REN)

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

Full name of child: Date of birth:

Education (name & address of school & grade):

Health conditions:

1) Have any of your children ever been arrested for an offense other than a traffic infraction? Yes No

If yes, please explain the charges and any convictions:

2) Are any of your children currently on probation or parole? Yes No

If yes, please explain the circumstance:

3) Have any of your adult children ever been investigated for allegations of child neglect or abuse? Yes No

If yes, please explain the circumstances:

FAMILY HISTORY

Father: Mother: Sibling:

Sibling: Sibling:

HOUSEHOLD INFORMATION

Mailing Address City, State, Zip:

Describe your home (include number of bedrooms & bathrooms):

Have you ever had any previous adoptive placement(s)? Yes No

If yes, please describe:

Have you ever applied with another agency? Yes No

If yes, when and name of agency:

How long at present address?:

If you are a married couple: Date of marriage: Place of marriage:

If you are an unmarried couple: Length of domestic partnership/relationship:

OTHER MEMBERS OF THE HOUSEHOLD

Full Name: Gender: Date of Birth:

Relationship to Family: Occupation:

1) Have any of these members of the household ever been arrested for an offense other than a traffic infraction? Yes No

If yes, please explain the charges and any convictions:

2) Are any of these members of the household currently on probation or parole? Yes No

If yes, please explain the circumstance:

3) Have any of these members of the household ever been investigated for allegations of child neglect or abuse? Yes No

If yes, please explain the circumstances:

4) Have any of these members of the household ever been reported for allegations of domestic violence? Yes No

If yes, please explain the circumstances and outcome:

BIRTHPARENT INFORMATION

Birthmother

Name (last, first, middle):

Birthdate: Maiden name or aliases:

Ethnicity, race: Address:

Telephone number:

Birthfather

Name (last, first, middle):

Birthdate: Aliases:

Ethnicity, race: Address:

Telephone number:

PLACEMENT DETAILS

Describe fully how you first learned of the child, if and when you met the birthparents, and how you secured this child for adoption. Include specific information pertaining to the transfer of custody and the name of any intermediary involved:

Birthparent:

Has the Biological Mother received or been promised financial assistance, either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of her child, and its placement for adoption? Yes No

If yes, please describe type and amount of assistance:

Marital status of biological mother:

Single (never married) Separated (not divorced) Legally married Common-law marriage Divorced Widowed

Hospital:

Expenses related to adoption:

Adoption service:

Physician: Attorney:

THE BIOLOGICAL FATHER

Was Was not married to the Biological Mother at the time the child was conceived or was born, and his paternity

Has Has not been disproved by a final paternity order of a court;

Did Did not marry the Biological Mother after the child was born and recognize the child as his own, and his paternity

Has Has not been determined to be the child's father by a final paternity order of a court; and

Has Has not legitimated the child by a final court order.

Has Has not lived with the child;

Has Has not contributed to his or her support;

Has Has not provided for the Biological Mother's support (including medical care) during her pregnancy or hospitalization for the birth of the child; and

Has Has not made any attempt to legitimate the child.

CHILDRENS’ INFORMATION

Child #1

Name of child: Child's Soc. Sec. No.:

Current weight: Eye color: Hair color:

Place of birth: Gender: Birthdate:

State and county of child's birth:

Name of hospital: Address of hospital:

Attending physician:

Height: Current age:

Has the child ever been known by another name? Yes No

Do you believe the child was exposed to alcohol or drugs in utero? Yes No

Do you believe or suspect the child was subjected to physical, sexual or emotional abuse or neglect prior to placement in your home? Yes No

If yes, please provide details:

Briefly describe the adjustment of your child(ren) to your home:

Describe current and future planned child care arrangements:

Describe, if any, religious training plans of the child(ren):

Date custody was (or will be) transferred to adoptive parents:

Child #2

Name of child: Child's Soc. Sec. No.:

Current weight: Eye color: Hair color:

Place of birth: Gender: Birthdate:

State and county of child's birth:

Name of hospital: Address of hospital:

Attending physician:

Height: Current age:

Has the child ever been known by another name? Yes No

Do you believe the child was exposed to alcohol or drugs in utero? Yes No

Do you believe or suspect the child was subjected to physical, sexual or emotional abuse or neglect prior to placement in your home? Yes No

If yes, please provide details:

Briefly describe the adjustment of your child(ren) to your home:

Describe current and future planned child care arrangements:

Describe, if any, religious training plans of the child(ren):

Date custody was (or will be) transferred to adoptive parents:

SCHOOL INFORMATION (COMPLETE THIS SECTION IF CHILD(REN) ATTENDS SCHOOL).

Child #1:

Name of school: School address:

School phone:

Registered name: Teacher’s name:

Grade level:

Child #2:

Name of school: School address:

School phone:

Registered name: Teacher’s name:

Grade level:

FINANCIAL INFORMATION

MONTHLY INCOME

Gross Wages

First Petitioner: $

Second Petitioner: $

Net Wages

First Petitioner: $

Second Petitioner: $

Other Income (interest, property, dividends, etc.): $

Total Gross Income: $

MONTHLY EXPENSES

Housing (include taxes, insurance, & utilities): $

Insurance: $

Food/Clothing: $

Legal Obligations (child support, alimony, etc.): $

Extraordinary Expenses: $

Total = $

MONTHLY CONSUMER DEBT PAYMENTS

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Item Termination Date Balance Due $

Monthly Payment:

If you own your home, please indicate the following: Purchase Price $ Balance Due $

FINANCIAL ASSETS

Savings $ Investments $ Stocks, Bonds $ Real Property $

Other Resources $

I/We filed both state and federal income tax returns last year. Yes No If no, state reason:

I/We have had the occasion to file for bankruptcy. Yes No If yes, state reason:

INSURANCE

Does your family have health and hospitalization insurance that covers all family members? Yes No If yes, indicate the name of insurance carrier and address:

Name and address of family physician:

Name and address of pediatrician:

What provisions for medical care will be provided for the child(ren)?

Check the types of insurance coverage your family has and briefly describe each coverage.

GENERAL INFORMATION

The following is a list of safety issues and practices. Please check each issue and/or practice that applies to your home. If a situation does not apply to your home, please mark N/A.

All medications are locked up or stored in a manner to prevent access by children.

In our automobile(s), safety belts and approved infant and child seats and restraints are use in accordance with state law.

Operational smoke detectors are used in bedroom areas and in areas that pose a fire risk.

A charged general purpose fire extinguisher is on hand for emergency use.

Cleaning supplies, pesticides and other toxic substances are not kept in food storage areas and are inaccessible to young children.

All hot surfaces, such as wood stoves or fireplace inserts, have been made inaccessible to children with screening or other protective barriers.

We have an adequate septic and sewage disposal system.

Electrical outlets and sockets are covered or equipped with protective devices to prevent electrical shock.

Electrical wiring is enclosed.

Bunkbeds are not used for children under five.

The temperature of the hot water heater is maintained between 105 - 120 degrees fahrenheit.

Our family has and all family members are familiar with a fire evacuation plan.

Our pets are free of disease and pose no physical or health risk to children.

A first aid kit is in our home.

A first aid kit is in our car(s).

Adults in the home have taken a class in cardio-pulmonary resuscitation.

All guns and ammunition are locked up and guns are unloaded with the firing pins removed.

The swimming pool/hot tub/spa has either a five-foot fence constructed so that it does not obscure the pool/hot tub/spa from view around it with a self-latching gate or an approved pool/hot tub/spa cover.

All stairways have a protective barrier or other device to prevent infants or small children from injuries on stairways.

Our well has been certified free of impurities by the health department or a licensed water inspection company.

I/we have the following amount available to fund the adoption (may affect options that can be pursued):

Up to $1,000 $1,000 to $5,000 $5,000 to $10,000

$10,000 to $20,000 $20,000 to $30,000 Over $30,000

Do you have a completed home study? Yes No

Has an adoption ever been denied to you? Yes No

REFERENCES

Please give names and addresses of four references who are not related. It is suggested that at least one be a business associate other than an employer, and at least two be friends (preferably with children) who have knowledge of your home environment and lifestyle.

Your attorney or physician may not be given as a reference.

Name: Address/Phone: Relationship: How long known?

Name: Address/Phone: Relationship: How long known?

Name: Address/Phone: Relationship: How long known?

Name: Address/Phone: Relationship: How long known?

Please list three references who have known you for at least five years. Include a family member, a co-worker, and a social friend or neighbor.

Name: Address: Relationship: How long known?

Name: Address: Relationship: How long known?

Name: Address: Relationship: How long known?

SIGNATURES