Adoption Information Sheet Arkansas
Before a final decree in an adoption case in the State of Arkansas is made, this information sheet has to be completed and submitted by the defendant in the case.
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County: _____________ Date: _________________ State of Birth Age Current State Race Gender Adoptee 1. Type of Decree: Interlocutory Final Date Decree Entered: ___________ 2. Is Petitioner a step-parent? No Yes If yes, notice to grandparents? No Yes 3. Is/are the petitioner(s) related to the person to be adopte d? No Yes If Yes, relationship to adopted person: Gra ndparent; Aunt/Uncle ; Cousin; Sibling; or Other: _____________________________________________ 4. Was the petitioner(s) given a detailed written health, genetic, and social history of the adoptee? No Yes 5. Home Study Waived? No, answer question 5a Yes, answer question 5b 5a. Cost of Home Study: $____________ Completed by Licensed Social Worker: Yes No 5b. If yes, waived because Adult adoptee; Step-parent; or Related 2 nd degree 6. Total cost of adoption paid by the petitioner(s): $_____________ 7. Petitioner(s): Married; if yes, numb er of years of marriage: ___ years ___ months Single; if Yes, Never Married, Divorced, Separated Widow/Widower 8. Petitioner #1: _____ Gender; _______ Race; ____Age; ______State of Residence; _____ Years in State of Residence Petitioner #2: _____ Gender; ____________ Race; _____Age; ______State of Residence; _____ Years in State of Residence Did the case go through the Interstate Compact for the Placement of Children? No Yes 9. Was this an international adopti on? No Yes, country born in: _____ _____; country placed from: ________ 10. Criminal Background Check: FBI Arkansas State Police If criminal history, list all felony and misdemeanor convictions including dates of conviction, sentence, and whether conviction was sealed or expunged: Petitioner #1:__________________________________________________________________ Petitioner #2: _________________________________________________________________ 11. Was a licensed physician primarily responsi ble for making the placement of the adoptee? No Ye s 12. Was a lic ensed attorney primarily responsible for making the placement of the ad optee? No Yes 13.Was Adoption primarily handled by: Licensed Arkansas Adoption Agency; Name: _____________________________________ Out-of-State Agency or individual name: _________________________________________ Departme nt of Human Services 14. Birth family information: 14a. State of Residence of Bi rth Mother: ___________; Number of years in State of Residence: ___ years 14b. Age of Birth Mother: ______ 14c. Birth Father: Legal or Putative, if Putative, on Putative Father Registry: No Yes 14d. Consent of Fat her Required? : No Yes 15. Does petitioner(s) plan to allow cont inued contact with birth parents? No Yes 16. Length of time from application to placement of child in home: ___ years ___ months 17. Was a surrogate mother used? No Yes Signature of person completing form: ___________________________________ Printed name of person completing form: ________________________________ Date completed: __________________ If petitioner completed form, plea se just write “petitioner” in signature and printed name fields. Pursuant to Ark. Code Ann. § 9-9- 104, before the entry of an interlocutory or final decree of adoption, the petitioner s hall co mplete the adoption information sheet and return it to the clerk. The clerk shall forward the complete d adoption information sheet to the DHS Office of Chief Counsel, P.O. Box 1437, SLOT S260, Little Rock, AR, 72203-1437. Adoption Information Sheet County: _____________ Date: _________________ State of Birth Age Current State Race Gender Adoptee USE THIS TO ADD ADDITIONAL CRIMINAL HISTORY If criminal history, list all felony and misdemeanor convictions including dates of conviction, sentence, and whether conviction was sealed or expunged: Petitioner #1: Petitioner #2: Adoption Information Sheet ADOPTION INFORMATION SHEET INSTRUCTION GUIDE The Adoption Information Sheet should be completed by either the petitioners or the attorney for the petitioners. Please fill in the top section of the form. These fields include the County in which the adoption is taking place, the date the form is filled out, and the Adoptee’s name, age, current state of residence, race, and gender. 1. If the juvenile has been in the petitioner’s home for more than six months, a Final Decree would be f iled. In the event the juvenile has been in the home less than six months, an Interlocutory Decree would be filed. 2. Check whether or not the petitioner(s) is/are a step -parent and whether or not the grandparents were notified. 3. Check whether the petitioner(s) is/are related to the juvenile being adopted. 4. Only answer if the petitioner(s) were given a detailed health, genetic, and social history of the juvenile. 5. Answer whether a home study conducted on the petitioner(s) and what was the cost of the home study. Also please answer whether the home study was completed by a licensed social worker. If a home study was waived, provide the reason . 6. Total cost of the adoption to the petitioner(s). This includes any and all fees incurred from the onset of the adoption. 7. Answer these questions as related to the petitioner(s). 8. Answer these questions as related to the petitioner(s). Also answer whether or not the case had to go through the Interstate Compact for the Placement of Children (ICPC). ICPC assistance would occur if the juvenile was being placed in a home outside the State of Arkansas. 9. Answer whether the juvenile is from outside the Un ited States of America. If the juvenile is from outside the USA , pleas e write in the country the juvenile was born in and the country the juvenile was placed from. 10. Answer these questions as related to the petitioner(s). Please be sure to include dates of conviction, sentence, and whether the conviction was sealed or not. If additional space is needed to list your criminal history, please use page 2 to give a complete answer. 11. Answer whether the petitioner(s) was/were made aw are of the juvenile by a licensed physician. 12. Answer whether the petitioner(s) was/were made aware of the juvenile by a licensed attorney. 13. Answer whether the adoption was handled by an Agency (In -State or Out -of -State) or the Department of Human Services. If handled by an Adoption Agency, please list the name of the agency or the individual who handled the adoption. 14. Please provide the requested information on the birth family of the adoptee. 15. Answer whether the petitioner(s) plan(s) to allow the juvenile to have contact with his/her birth parents. 16. Pleas e provide the length of time the adoptee has been in the home of the petitioner(s). 17. Answer whether the juvenile was conceived using a surrogate mother. An Adoption Information Sheet needs to be completed for each child being adopted.
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