Adoption Data Card

14 Jun, 2017 Adoption 0

This data card has to be completed and sent in case of going through an adoption case. There are no fees associated with filing and processing this card.

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ADOPTION DATA CARD
DSHS 10-114 (REV. 06/2001)

ADOPTION DATA CARD, DSHS 10-114(X)
INSTRUCTIONS
Why information is needed and legal authority:
According to RCW 26.33.300, an Adoption Data Card must be completed and filed with the clerk of the court on behalf of the petitioner
for each individual adopted. Under the federal requirements of the Adoption and Foster Care Analysis and Reporting System
(AFCARS), the State must report on all adoptions which occurred since October 1, 1994, and in whose adoption Title IV-B/IV-C agency
has had any involvement. AFCARS reports on all other adoptions are encouraged but are voluntary. Reports on the following
adoptions are mandated:
a. All children adopted who had been in foster care under the responsibility and care of the Department of Social and Health
Services (DSHS) and who were subsequently adopted whether special needs or not and whether subsidies are provided or
not.
b. All special needs children who were adopted in the State of Washington, whether or not they were in the public foster care
system prior to their adoption and for whom non-recurring expenses were reimbursed.
c. All children adopted for whom an adoption assistance payment or service is being provided based on arrangements made
by or through DSHS.
SECTION I. CHILD INFORMATION
Item 1 – 5
Item 6 Self-explanatory.
In general, a person’s race is determined by how others define them or by how they define themselves. In the case of
young children, parents determine the race of the child.
White:

Black or African American:
American Indian/Alaskan Native:

Asian:

Native Hawaiian or other Pacific Islander: a person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
a person whose ancestry is any of the black racial groups of Africa.
a person having origins in any of the original peoples of North or South America
(including Central American) and who maintains tribal affiliation or community
attachment.
a person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
Item 7
Item 8
Item 9
Item 10

Item 11
Item 12 Self- explanatory
Use the State definition of special needs as it pertains to a child eligible for an adoption subsidy.
Check the factor or condition for categorization as special needs. Check all that apply.
Check the factor or condition as defined by the State and clinically diagnosed by a qualified professional. Check all that
apply.
Date child was placed with adoptive family, either on foster or adoptive basis.
Date child was placed in foster care following most recent removal from birth family.
SECTIONS II. BIRTH PARENT INFORMATION
Item 1
Item 2
Item 3
Item 4

Item 5 Enter the year of birth for each birth parent. If the exact year of birth is unknown, enter an estimated year of birth.
Race: see instructions and definitions under SECTION I., Item 6.
Self-explanatory.
Self-explanatory.
Enter the month, date, and year of termination of parental rights (TPR), voluntary relinquishment or death of birth
mother or father.
SECTIONS III. PETITIONERS INFORMATION
Item 1
Item 2
Item 3 Enter the year of birth for each petitioner. If the exact year of birth is unknown, enter an estimated year of birth.
Self-explanatory.
Race: see instructions and definitions under SECTION I., Item 6.
Item 4
Item 5 Self-explanatory.
Self-explanatory.

ADOPTION DATA CARD
DSHS 10-114 (REV. 06/2001)
SECTION IV. ADOPTION PLACEMENT INFORMATION
Item 1
Indicate the location of the individual or agency that had custody or responsibility for the child at the time of initiation of
adoption proceedings.
Item 2 Indicate the individual or agency which placed the child for adoption.
Public agency:
Private agency:
Public DSHS & Private Agency:
Birth parent:
Independent Person:
Tribal agency:
a unit of State or local government.
a for-profit or non-profit agency or institution.
a DSHS agency and a private agency.
the parent(s) placed the child directly with the adoptive parent(s).
a doctor, a lawyer, or some other individual.
a unit within one of the Federally recognized Indian Tribes or Indian Tribal
Organization.
Item 3 Indicate the prior relationship(s) the child had with the adoptive parent(s).
Stepparent:
Other relative of child:
Foster parent:

Non-relative: spouse of the child’s birth mother or birth father.
a relative of the birth parents through blood or marriage.
the child was placed in a non-relative foster family home with a family
that later adopted him or her. The placement could have been for the
purpose of either adoption or foster care.
adoptive parent fits into none of the categories above.
Item 4 (a)
(b)
(c)
(d)
(e) Enter “yes,” if this child was adopted with a signed adoption support agreement;
If a monthly financial payment is being paid mark yes;
Enter the amount of the monthly maintenance;
If the child is eligible for medical services under Title XIX or XX (state or federal) mark yes;
If the adoption support claimed by the state is reimbursement under Title IV-E mark yes. (ask adoption support
program manager if you don’t know the answer).

Item 5 Self-explanatory.
SECTION V AND VI. AGENCY OR INDIVIDUAL COMPLETING POST PLACEMENT REPORT AND INDIVIDUAL COMPLETING
DATA CARD
All items are self-explanatory.
SECTION VII COURT INFORMATION
All items are self-explanatory.
TO ORDER THIS FORM:
Use the DSHS 17-011(X) Forms and Publications Request form or your office letterhead providing the following information:
Complete office name, mail stop and/or street address – (NO POST OFFICE BOXES) city, state, and zip code.
Name and telephone number of requestor (and person receiving the order if different). Orders must include the form number (10-
114(X), title, and quantity requested. Please include the exact number of forms you need.
Mail your request to DSHS Forms and Publications Warehouse, MS 45816, PO Box 45816, Olympia, WA 98504-5816, Fax to 360-
664-0597, or email to DSHS [email protected]
. If you have Outlook or Exchange e-mail systems then you can utilize
the DSHS 17-011 Word 7 version on the intranet to order the form. It can be automatically sent by using the send buttons on the
bottom of the form (does not work with GroupWise).

ADOPTION DATA CARD
DSHS 10-114 (REV. 06/2001)

DEPARTMENT OF SOCIAL AND HEALTH SERVICES
CHILDREN'S ADMINISTRATION

ADOPTION DATA CARD Return To:
ADOPTIONS
PO BOX 45713, OLYMPIA
WA 98504-5713

According to RCW 26.33.300, an Adoption Data Card must be completed and filed with the clerk of the court on behalf of
the petitioner for each individual adopted. No amended birth certificate will be issued until the data card has been
completed and filed with the Department of Social and Health Services (DSHS). Data collection will be used to provide
statewide adoption statistics.
I. CHILD INFORMATION
1. PLACE OF BIRTH (County/Country/Alien status):
2. STATE:
3. U.S. CITIZEN AT TIME OF PLACEMENT:
Yes No
4. DATE OF BIRTH:

5. SEX:
Male Female
6. RACE (Check all that apply):
White
Black or African American
American Indian/Alaska Native
Asian
Native Hawaiian or other Pacific Islander

7. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM
TO BE SPANISH/HISPANIC/LATINO?
No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican/Mexican American/Chicano
Yes, Puerto Rican
Other S panish/His panic/Latino
8. DOES THIS CHILD HAVE SPECIAL NEEDS?
Yes
No
Unable to determine
9. SPECIAL NEEDS BASIS (Check all that apply):
Not applicable
Medical conditions or mental, physical,
or emotional disabilities.
Age
Racial/origin background
Part of Sibling group
Other:
10. MEDICAL CONDITIONS OF MENTAL, PHYSICAL, OR EMOTIONAL DISABILITIES (Check all that apply):
Mental retardation
Visual/hearing impaired
Physical disability
Emotional disability
Other medical disability:

11. DATE CHILD WAS PLACED IN HOME OF PETITIONERS:
12. DATE OF INITIAL FOSTER CARE PLACEMENT:
II. BIRTH PARENT INFORMATION
MOTHER'S INFORMATION FATHER'S INFORMATION
1. YEAR OF BIRTH:

2. RACE (Check all that apply):
White
Black or African American
American Indian/Alaska Native
Asian
Native Hawaiian or other Pacific Islander
3. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM
TO BE SPANISH/HISPANIC/LATINO?
No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican/Mexican American/Chicano
Yes, Puerto Rican
Other Spanish/Hispanic/Latino
4. MARITAL STATUS AT TIME OF BIRTH:
Married Single Unable to determine
5. TERMINATION OF PARENTAL RIGHTS (TPR):
Court ordered TPR date:
Date of Voluntary Relinquishment:
Date of Death:
1. YEAR OF BIRTH:

ADOPTION DATA CARD
DSHS 10-114 (REV. 00/2001)
III. PETITIONER (S) INFORMATION
PETITIONER 1 INFORMATION PETITIONER 2 INFORMATION
1. YEAR OF BIRTH:

2. SEX:
Male Female
3. RACE (Check all that apply):
White
Black or African American
American Indian/Alaska Native
Asian
Native Hawaiian or other Pacific Islander
4. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM
TO BE SPANISH/HISPANIC/LATINO?
No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican/Mexican American/Chicano
Yes, Puerto Rican
Other S panish/His panic/Latino
5. MARITAL STATUS AT TIME OF BIRTH:
Married Couple
Unmarried Couple
Single Man
Single Woman
IV. ADOPTION PLACEMENT INFORMATION
1. LOCATION OF AGENCY/
INDIVIDUAL WITH CUSTODY
WHEN PETITION FILED:
Within state
Another state
Another country
2. AGENCY/INDIVIDUAL WHICH PLACED CHILD FOR ADOPTION:
Public agency Birth Parent
Private agency Independent person
Name:

Public DSHS and private agency Tribal agency
PA Name:

3. CHILD'S RELATIONSHIP TO
ADOPTIVE PARENTS:
Stepparent
Other relative of child
Foster Parent of child
Non-related
4. ADOPTION SUPPORT INFORMATION: YES NO
a. Is there a signed adoption support agreement, if no, skip to number 5. . . . . . . . . . . . . . . . . . . . . . .
b. Is monthly maintenance (state or federal) being received?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Enter the amount of monthly maintenance: $

d. Is Title XIX/XX medical being received? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. Is the child I-VE eligible?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5. PLACEMENT INFORMATION (TO BE COMPLETED IF DSHS ADOPTION): YES NO
Was child in state funded foster care prior to adoptive placement?. . . . . . . . . . . . . . . . . . . . .
Was child placed with own (birth) siblings in this adoptive home? . . . . . . . . . . . . . . . . . . . . . .
Was child in prior adoptive or pre-adoptive placement?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

V. AGENCY OR INDIVIDUAL COMPLETING POST PLACEMENT REPORT (CHECK ONE )
Department of Social and Health Services (DSHS)
Washington Private Child Placement Agency
Court employee
Other court appointed individual
Report not
completed
IV. INDIVIDUAL COMPLETING FORM
NAME:

TELEPHONE NUMBER :

ADDRESS:

CITY:

STATE:

ZIP CODE:

THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
SIGNATURE:

VII. COURT INFORMATION (TO BE COMPLETED BY THE COURT )
PETITION NUMBER:

DATE PETITION FILED:

FINAL DECREE GRANTED:

COUNTY:

COUNTY CODE:

COURT CLERK OR DESIGNEE’S SIGNATURE:

TO ORDER THIS FORM:
Mail your request to DSHS Forms and Publications Warehouse, MS 45816, PO Box 45816, Olympia, WA 98504-5816, Fax to 360-664-0597, or email to
DSHS [email protected]
. If you have Outlook or Exchange e-mail systems then you can use the DSHS 17-011 Word 7 version on the
intranet. It can be automatically sent by using the send buttons on the bottom of the form (does not work with GroupWise).

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