Application for Domestic Adoption "*" indicates required fields Applicant InfoName 1* First Middle Last Legal Name 1*Please type your legal name. All legal documents will reflect your name as indicated below.Preferred Pronouns Name 1*she, her, hershe, him, histhey, them, theirsMaiden Name Name 1 Last Other Name 1Please indicate whether you have been known by any other names in the last five years.Name 2* First Middle Last Legal Name 2*Please type your legal name. All legal documents will reflect your name as indicated below.Preferred Pronouns Name 2*she, her, hershe, him, histhey, them, theirsMaiden Name Name 2 Last Other Name 2Please indicate whether you have been known by any other names in the last five years.Contact InfoAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Mobile Name 1*Home Phone Name 1Work Phone Name 1Email Name 1* Mobile Name 2*Home Phone Name 2Work Phone Name 2Email Name 2* Adoption Line Phone NumberHousehold CompositionDo you have any children together?* Yes No First Child's NameFirst Child's Date of Birth Month Day Year First Child's Status Biological Adopted Second Child's NameSecond Child's Date of Birth Month Day Year Second Child's Status Biological Adopted Other Members of HouseholdName, age, and relationship. For example: Helen Smith, 69, mother-in-lawAdoption QuestionsWhat factor motivated you to seek private adoption?*Would you consider a child with mixed racial parentage? If so, describe.*Up to what age would you consider a child for adoption?*If the child is male, would you want him circumcised in hospital?* Yes No If you are successful in adoptiong a child, do you intend to tell the child he/she is adopted?* Yes No 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?* Yes No Would you agree to meet the birth parents prior to the adoption if they so desire?* Yes No If you are working outside the home, will you continue to work?* Yes No If you continue to work, who will be the primary caretaker of the child?Marital HistoryMarriage DateMarriage Location City State / Province / Region Prior MarriagesReason for Termination Marriage 1 Name 1Dissolution Date Marriage 1 Name 1 Month Day Year Custody of Children Marriage 1 Name 1First Child of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Second Child of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Reason for Termination Marriage 2 Name 1Dissolution Date Marriage 2 Name 1 Month Day Year Custody of Children Marriage 2 Name 1First Child of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Second Child of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Reason for Termination Marriage 1 Name 2Dissolution Date Marriage 1 Name 2 Month Day Year Custody of Children Marriage 1 Name 2First Child of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Second Child of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Reason for Termination Marriage 2 Name 2Dissolution Date Marriage 2 Name 2 Month Day Year Custody of Children Marriage 2 Name 2First Child of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Second Child of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Personal HistoryDate of Birth Name 1* Month Day Year Birthplace Name 1*Citizenship Name 1*Ancestry Name 1*Religion Name 1*Siblings Name 1*Please list number of brothers and sisters. If none, write none. For example: 2 sisters, 1 brother.Parents Name 1*Please name them and indicate if they are alive to be grandparents to your adopted childDate of Birth Name 2* Month Day Year Birthplace Name 2*Citizenship Name 2*Ancestry Name 2*Religion Name 2*Siblings Name 2*Please list number of brothers and sisters. If none, write none. For example: 2 sisters, 1 brother.Parents Name 2*Please name them and indicate if they are alive to be grandparents to your adopted childEmploymentOccupation Name 1*Employer Name 1*Title, Length of Employment Name 1*Salary Name 1*Other Income Name 1If less than 2 years, list previous employer Name 1Occupation Name 2*Employer Name 2*Title, Length of Employment Name 2*Salary Name 2*Other Income Name 2If less than 2 years, list previous employer Name 2Physical DescriptionHeight, Weight Name 1*Hair Color, Eye Color Name 1*Height, Weight Name 2*Hair Color, Eye Color Name 2*Medical HistoryPlease complete the following questions. Type "none" if not applicable.Physical Disorders Name 1*Psychiatric Problems Name 1*Drug or Alcohol Issues Name 1*Any other physical or mental factors that might affect life span or ability to raise a family Name 1*Physical Disorders Name 2*Psychiatric Problems Name 2*Drug or Alcohol Issues Name 2*Any other physical or mental factors that might affect life span or ability to raise a family Name 2*Educational HistoryHigh School Name 1*College Name 1Years Completed, Degree, Area of Study Name 1Graduate School, Degree, Area of Study Name 1Hobbies or Special Interests Name 1High School Name 2*College Name 2Years Completed, Degree, Area of Study Name 2Graduate School, Degree, Area of Study Name 2Hobbies or Special Interests Name 2Personal Court ActionsCivil Name 1* Yes No If yes, please explain:*Criminal Name 1* Yes No If yes, please explain:*Bankruptcy Name 1* Yes No If yes, please explain:*Have you ever been arrested Name 1* Yes No If yes, please explain:*Child abuse, neglect, or abandonment Name 1* Yes No If yes, please explain:*Civil Name 2* Yes No If yes, please explain:*Criminal Name 2* Yes No If yes, please explain:*Bankruptcy Name 2* Yes No If yes, please explain:*Have you ever been arrested Name 2* Yes No If yes, please explain:*Child abuse, neglect, or abandonment Name 2* Yes No If yes, please explain:*Adoption HistoryHave you ever applied for adoption and been rejected?* Yes No If, yes, why?*Previous AdoptionsState of BirthState/County of FinalizationDate of Finalization Month Day Year Type of Adoption Agency Private Real EstateHome Address(Primary Residence) Address if Different than address listed at top of form Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Market Value*Mortgage Balance / Monthly Rent*Other ResidencesMarket ValueMortgage BalanceInsuranceMedical Insurance Company*Life Insurance Company Name 1Life Insurance Company Name 2Face Value Name 1Face Value Name 2SignaturesConsent Name 1* I certify that my answers are true to the best of my knowledge.Consent Name 2* I certify that my answers are true to the best of my knowledge.Date* Month Day Year PhoneThis field is for validation purposes and should be left unchanged.
