Adoption Questionaire

For use as attorney-client work product only.


Today's Date:
Client Name:
Name of Adoptive Father:
County of Residence:
Telephone Number:
Social Security Number:
Previous Name(s): None oras follows:
Date of Birth:	Age:
Name of Adoptive Mother:
Telephone Number:
Social Security Number:
Date of Birth:	Age:
Maiden Name and Other Previous Name(s):
Marriage Date of Adoptive Parents (or Biological Mother/Stepfather for Stepparent Adoption):
Name of Biological Mother:
Residence Street Address:
City/ State Zip:
County of Residence:
Telephone Number:
Social Security Number:
Date of Birth:	Age:
State and County of Mother's Birth:

The Biological Mother has received or been promised the following financial asssistance, either directly or indirectly, from whatever source, in connection with her pregnancy, the birth of her child, and its placement for adoption: None ORAs follows:

Marital Status of Biological Mother: (check and complete as applicable) Single (never married) Separated (not divorced)
Legally married Common-law marriage
Divorced Widowed

If single, seperated, married or common-law, please complete the following:

Spouse's name: Spouse's last known address:

State and County of Marriage: Date relationship began:

Marriage Date: Separation Date (if applicable):

If divorced, please complete the following:

Former spouse's name:

Former spouse's last known address:

State and County of Marriage: State and County of Divorce:

Marriage Date: Divorce Date:

If Widowed, please complete the following:

Deceased spouse's name:

State and County of Marriage: State and County of Spouse's Death:

Marriage Date: Date of Spouse's Death:

Name of Biological Father:

Biological Mother will not identify because:

Residence Street Address:

City/State Zip:

County of Residence:

Telephone Number:

Social Security Number:

Date of Birth: Age:

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 disproved by a final paternity order of a court;

(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.

Current Name of Child:

Sex: Male Female

Child Currently Resides With:

Residence Street Address:

City/State Zip:

County of Residence:

Telephone Number:

Child's Social Security Number:

Child's Date of Birth: Age:

State and County of Child's Birth:

Date Custody was (OR Will Be) transferred to adoptive parents:

Child's Name will be changed to:

If additional children are to be adopted, please complete a separate section for EACH child.

REQUIRED DOCUMENTS:
BIRTH CERTIFICATE OF EACH CHILD TO BE ADOPTED
MARRIAGE CERTIFICATE OF ADOPTIVE PARENTS
FINAL DECREE OF DIVORCE FROM BIOLOGICAL FATHER
(FOR STEPPARENT ADOPTION)

Please also complete Form 413(DHR).