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.

Extracted Text for Proper Search

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.