Application for Single Parent Domestic Adoption "*" indicates required fields Applicant InfoName* First Middle Last Preferred Pronouns*she, her, hershe, him, histhey, them, theirsLegal Name* Please type your legal name. All legal documents will reflect your name as indicated below.Maiden Name/Alias Last Please indicate whether you have been known by any other names in the past 5 yearsContact 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 Phone* Home Phone Work PhoneEmail* Adoption Line Phone NumberHousehold CompositionDo you have children?* Yes No First Child's Name First Child's Date of Birth Month Day Year First Child's Status Biological Adopted Second Child's Name Second Child's Date of Birth Month Day Year Second Child's Status Biological Adopted Other Members of the Household Name, 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 Date Month Day Year Marriage Location City State / Province / Region Prior MarriagesReason for Termination Marriage 1 Dissolution Date Marriage 1 Month Day Year Custody of Children Marriage 1 Child of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Child 2 of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Child 3 of Prior Marriage 1 First Last Date of Birth Month Day Year Status Biological Adopted Reason for Termination Marriage 2 Dissolution Date Marriage 2 Month Day Year Custody of Children Marriage 2 Child 1 of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Child 2 of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Child 3 of Prior Marriage 2 First Last Date of Birth Month Day Year Status Biological Adopted Previous AdoptionsState of Birth State/County of Finalization Date of Finalization Month Day Year Type of Adoption Agency Private Personal HistoryDate of Birth* Month Day Year Birthplace* Citizenship* Ancestry* Siblings* Please list number of brothers and sisters. If none, write none. For example: 2 sisters, 1 brother.Parents* Please name them and indicate if they are alive to be grandparents to your adopted childEmploymentOccupation* Employer* Title, Length of Employment* Salary* Other Income If less than 2 years, list previous employer Physical DescriptionHeight, Weight* Hair Color, Eye Color* Medical HistoryPlease complete the following questions. Type "none" if not applicable.Physical Disorders* Psychiatric Problems* Drug or Alcohol Issues* Any other physical or mental factors that might affect life span or ability to raise a family* Educational HistoryHigh School* College Years Completed, Degree, Area of Study Graduate School/Degree of Study Hobbies or Special Interests Personal Court ActionsCivil* Yes No If yes, please explain:*Criminal* Yes No If yes, please explain:*Bankruptcy* Yes No If yes, please explain:*Have you ever been arrested?* Yes No If yes, please explain:*Child abuse, neglect, or abandonment* Yes No If yes, please explain:*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 Residences Market Value Mortgage Balance InsuranceMedical Insurance Company* Name 1: Life Insurance Company Name 1: Face Value SignatureConsent* I certify that my answers are true and complete to the best of my knowledge.Date Month Day Year CommentsThis field is for validation purposes and should be left unchanged.