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Application for Domestic Adoption

"*" indicates required fields

Applicant Info

Name 1*
Please type your legal name. All legal documents will reflect your name as indicated below.
Maiden Name Name 1
Please indicate whether you have been known by any other names in the last five years.

Name 2*
Please type your legal name. All legal documents will reflect your name as indicated below.
Maiden Name Name 2
Please indicate whether you have been known by any other names in the last five years.

Contact Info

Address*


Household Composition

Do you have any children together?*
First Child's Date of Birth
First Child's Status
Second Child's Date of Birth
Second Child's Status
Name, age, and relationship. For example: Helen Smith, 69, mother-in-law

Adoption Questions

If the child is male, would you want him circumcised in hospital?*
If you are successful in adoptiong a child, do you intend to tell the child he/she is adopted?*
If the birth parent were to give you a letter to be given to the child in the future explaining why she placed the child for adoption, would you give the child the letter?*
Would you agree to meet the birth parents prior to the adoption if they so desire?*
If you are working outside the home, will you continue to work?*

Marital History

Marriage Location

Prior Marriages

Dissolution Date Marriage 1 Name 1
First Child of Prior Marriage 1
Date of Birth
Status
Second Child of Prior Marriage 1
Date of Birth
Status

Dissolution Date Marriage 2 Name 1
First Child of Prior Marriage 2
Date of Birth
Status
Second Child of Prior Marriage 2
Date of Birth
Status

Dissolution Date Marriage 1 Name 2
First Child of Prior Marriage 1
Date of Birth
Status
Second Child of Prior Marriage 1
Date of Birth
Status

Dissolution Date Marriage 2 Name 2
First Child of Prior Marriage 2
Date of Birth
Status
Second Child of Prior Marriage 2
Date of Birth
Status

Personal History

Date of Birth Name 1*
Please list number of brothers and sisters. If none, write none. For example: 2 sisters, 1 brother.
Please name them and indicate if they are alive to be grandparents to your adopted child

Date of Birth Name 2*
Please list number of brothers and sisters. If none, write none. For example: 2 sisters, 1 brother.
Please name them and indicate if they are alive to be grandparents to your adopted child

Employment


Physical Description


Medical History

Please complete the following questions. Type "none" if not applicable.

Educational History


Personal Court Actions

Civil Name 1*
Criminal Name 1*
Bankruptcy Name 1*
Have you ever been arrested Name 1*
Child abuse, neglect, or abandonment Name 1*

Civil Name 2*
Criminal Name 2*
Bankruptcy Name 2*
Have you ever been arrested Name 2*
Child abuse, neglect, or abandonment Name 2*

Adoption History

Have you ever applied for adoption and been rejected?*

Previous Adoptions

Date of Finalization
Type of Adoption

Real Estate

Home Address
(Primary Residence) Address if Different than address listed at top of form

Insurance

Signatures

Consent Name 1*
Consent Name 2*
Date*
This field is for validation purposes and should be left unchanged.

Attorney Advertisement: The hiring of a lawyer and the contemplation of collaborative reproduction and adoption are significant matters that should not be based solely on advertisements, editorials and/or other social media communication such as websites and blogs. This website pertains to general information regarding collaborative or third-party reproduction and adoption and is not intended as legal advice nor does it imply an attorney/client relationship with Law Offices of Laurie B. Goldheim; the contents herein should not be relied upon without professional counsel. The Law Offices of Laurie B. Goldheim does not necessarily endorse, and is not responsible for, any third-party content that may be accessed through this website and expressly disclaims all liability in respect to actions taken or not taken based on any or all of the content of this website.

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