Legal Forms, Documents and Contracts

Over 4550 free forms and legal documents. Find and download the one you need!

Application for Adoption Social Study, Certification Home Study or Re-Certification and other docs

In order to be able to complete the following application form accurately, you have to carefully read those instructions. Use the attached checklist to make sure you haven’t forgotten anything.

Download

Extracted Text for Proper Search

1 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
 	
SUPERIOR COURT OF THE STATE OF ARIZONA	 	
Pima County Juvenile Court	 	
Adoptions & Guardianship Program	 	
2225 EAST AJO WAY	 	
TUCSON, ARIZONA 85713	-6295	 	
520	-724-2920; 520	-724	-9239	 	
FAX 520	-724	-4740	 	_________________________________________________________________________________________________________	 	
Congratulations on your decision to adopt!  The following steps outline t	he procedures required to complete an adoption through 	
the PCJCC Adoptions Program. 	Please read all directions prior to filling out the packet	. Keep this letter for your reference. If you 	
have any questions, please call Veronica at 740	-2920.	 	 
STEP 1: 	COMPLETE THE	 PACKET	     	
 	Use the checklist on the next page to guide you in completing all necessary forms and obtaining copies of documents 
before 	scheduling your fingerprint/document review appointment	. 	
 	If this is an adoption by a step parent, the birth p	arent married to the step parent must complete all the paperwork in the 	
packet as the second applicant	. 	
 	Once you have completed the Document Checklist, call our office (520	-724	-2920) to schedule an appointment for 	
fingerprinting, packet review and fee paym	ent. 	 	
            	 	
STEP 2: FINGERPRINTING, PACKET REVIEW & FEE PAYMENT	  	
Fingerprinting & Central Registry Records Check: 	 Call our program (520	-724	-2920) to schedule an appointment to be fingerprinted 	
and sign a release for a central registry record check 	at the Pima County Juvenile Court Center, 2225 E. Ajo Way.  	 	
 	All persons 18 years of age or older living in the home, 	except the birthparent	, must be fingerprinted.  The fee for 	each 	
person fingerprinted is $22	.00, in the form of money order or cashier’s 	check, made payable to AZ DPS.	 	
 	 Fingerprinting is done by appointment only, and must be done in our office. Fingerprint results are usually returned to our 
office four weeks after submission, but can take longer.	 	
 
Packet Review:	 Bring your completed packet	 and required (original) documents to your fingerprinting appointment. We will make 	
copies of your original documents. 	 	
 
Fee Payment:	 Bring your adoption fee payment	 of $25	 to the appointment. The payment can be in the form of personal check, 	
cashier’s che	ck or money order, or Visa/MasterCard. Your fee will be paid to the Clerk of Superior Court.	 	
 	Please note that the Adoption fee is to cover 	the cost to process	 your application for adoption and 	does not guarantee	 that 	
adoption will be recommended. 	 	
 	If a soc	ial study is required to complete your adoption an additional fee will be required.  	 	
 	The fee is 	non	-refundable	, even if the adoption is delayed or denied. Our social worker can further discuss with you what 	
may cause an adoption to be delayed or denied. 	 	
 	
Social Study Interview:  	Administrative orders allow for a social study to be conducted in certain situations.	 	
 	After our office has received your fingerprint results	 and CPS Central Registry Check	, we will review all information provided 	
and determine if a social study interview is applicable to your situation.  If so, we will mail you an appointment letter wit	h 	
the date and time of your Social Study Interview, which occurs in your home.  	 	
 	The home	 visit consists of a two hour (approximately) interview with our adoptions social worker.  The petitioners for 	
adoption and the child(ren) to be adopted must be present for the interview. 	 	
 	During the home visit, our social worker will be learning about you	r family and discussing topics such as criminal history, 	
CPS history, past and present relationships, family functioning, the birth parent(s) and the child(ren)’s understanding of th	e 	
adoption. If you have concerns about any of these topics, please contact	 our social worker (520	-724	-9239	) prior to your 	
home visit. 	 	
 	After the interview, our social worker will prepare a report for the Court which includes a recommendation as to whether 
the adoption appears to be in the best interest of the child(ren). 	 	 
STEP 	3: FINAL ADOPTION HEARING	 	
The final adoption hearing is usually held one to two months after all materials have been processed. The final adoption hear	ing is 	
set by the County Attorney’s office and 	must be attended by the	 petitioners and the subject child(	ren)	.  Adoption is a celebration 	
and you may invite family members and friends to attend the hearing with you.  	You will receive a letter once your family is ready to 	
meet with the County Attorney.	 	
 
 	
Veronica Hookland	 - Support 	Staff	 	Priscilla Ordonez 	- Case Worker

2 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
SUPERIOR COURT OF THE STATE OF ARIZONA	 	
Pima County Juven	ile Court	 	
Adoptions & Guardianship Program	 	
2225 EAST AJO WAY	 	
TUCSON, ARIZONA 85713	-6295	 	
520	-724-2920; 520	-724	-9239	 	
FAX 520	-724	-4740	 	
 
A N	ote to 	Prospective A	doptive 	Parents:	 	
 
The Juvenile Court Adoptions Program, the Judges and the County Attorney’s office 
encourage all families to have an open conversation with their child(ren) about the 
upcoming adoption.  Honesty, 	with age appropriate words and information	, is extremely 	
impo	rtant.  If you are concerned about having this conversation, please contact our social 	
worker, 	Priscilla Ordonez	, at 520	-724	-9239 	for some information and articles to assist 	
you.  	Below is a brief list of words and phrases to use to positively discuss adoptio	n.    	
Thank you for your time and attention to this important aspect of the adoption journey.	 	
 
Positive Language	 	Negative Language	 	
Birthparent	 	
Biological parent	 	
Birth child	 	
My child	 	
Born to unmarried parents	 	
Terminate parental rights	 	
Make/Made an adoption	 plan	 	
To parent	 you	 	
Biological or birthfather	 	
Making contact with	 	
Parent	 	
Was adopted	 	
Real parent	 	
Natural parent	 	
Own Child	 	
Adopted child; Own child	 	
Illegitimate	 	
Give up	 	
Give Away	 	
To keep you	 	
Real father	 	
Reunion	 	
Adoptive parent	 	
Is adopted	 	
 
 
 
 
 	
 	
Veronica Hookland	 - Support Staff	 	 Priscilla Ordonez 	- Case Worker

3 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
Talking to 	Children about Adoption	 	
What's the best way to handle my child's questions about her adoption?	 	
Many parents want to know when is the best time to tell a child she is adopted. The answer is that it is never too early to t	alk to 	
your child about adoption. Be	fore age 3, include age	-appropriate children's books on adoption as part of your child's reading 	
routine. Give your child information little by little, as much as she can understand. It may take years for your child to ful	ly 	
understand what adoption means.	 These early talks will give you practice in talking about adoption. They will also show your 	
child that it is OK to bring up the topic. 	 	
Here Are Some Tips On How To Talk About Adoption In Your Everyday Life:	 	
Tell the story	. Just as any child delights in the story of the day she was born, a child who is adopted will love to hear the details 	
of how she came into the family. Share with your child the joy you felt at bringing her home that very first day. Talk with h	er 	
about th	e many ways children join families	—whether by adoption or birth, or in foster care or stepfamilies.	 	
Share the memories	. During the adoption process, keep a scrapbook or journal the same way an excited mother does during 	
pregnancy. Keep track of important d	ates and steps in the process. Take pictures of the people and places involved in your 	
child's earlier life. These details will help make the adoption easier for your child to understand. You may want to place pi	ctures 	
in your child's room to encourage her	 to ask questions about her adoption. If you have an open adoption, you could frame a 	
picture of her birth parents. If she was adopted internationally, maybe frame a picture from her place of origin.	 	
Use the words	. The word adopted should become a part of 	your child's vocabulary early on. Find other words that everyone in 	
your family is comfortable with. The terms 	birth mother	 and 	birth father	 are very common. 	Biological parents	 is also used 	
frequently. Let your child know that the words 	mother	 and 	father	 have more than one meaning. A mother is someone who gives 	
birth to a child, but a mother is also someone who loves, nurtures, and guides a child to adulthood. Being a father also can 	have 	
different meanings.	 	
Adoptive parents often tell their child she is 	special because she was "chosen" or that she was "given up out of love." Though 	
the parents mean well, these statements may be very confusing to a child. Some children may feel that being chosen means 
they must always be the best at everything. This can le	ad to problems when they start to realize this is not possible. Telling your 	
child she was given up out of love may raise questions about what love is and whether others will give her up too. Some famil	ies 	
use the term "making an adoption plan" or “placed 	for adoption” instead of "giving up" their child.	 	
Don't wait	. The longer you wait to talk about adoption with your child, the harder it will be. Any level of openness you can build 	
when your child is young will help encourage her to ask more questions abou	t her adoption as she gets older.	 	
Ask for help	. If talking with your child about adoption is difficult, talk with your pediatrician. He or she can be a valuable source 	
of support, understanding, and resources.	 	
Questions Your Child Might Ask	 	
Even if you tal	k about adoption early and openly, at some point your child may begin to ask questions such as 	 	
 	"Did I grow in your body, Mommy?" 	 	
 	"W hy did my birth mother give me away?" 	 	
 	"Did she and my birth father love each other?" 	 	
 	"W hat was my name before I was adopt	ed?" 	 	
 	"W hat nationality am I?" 	 	
 	"Do I have brothers or sisters?" 	 	
Be honest and open	. If your child feels that you are not telling the whole story, he may look for answers somewhere else, like 	
from a relative or friend who may not know or may not share acc	urate information. Show your child that you are willing to talk 	
about the adoption. Tell him it's OK to bring it up with you.	 	
Avoid responding with your own worries	 like "Why do you want to know?" or "Are you unhappy with our family?" Your child's 	
curiosit	y is healthy and natural. It should not be discouraged or seen as a threat to you. Also be sure to only answer the 	
questions the child has asked, not what you think he should know.	 	
Don't force the issue on your child	. Some children are curious from the ver	y beginning. Others may be afraid to bring it up. 	
The best you can do is let your child know it is OK to talk about it. When your child is ready to know more, he will ask. 	 	
Questions Others May Ask	 	
Other people might ask questions that your child will not 	be able to answer, from innocent questions like:	 	
 	"W here did you get those big, blue eyes?"

4 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 
 	"Do you look more like your mom or your dad?"	 	
 
To important medical questions such as: 	 	
 	"Do you have a family history of heart disease, cancer, or diabetes?" 	 	
 	"W hat	 is your ethnic background?"	 	
 
Questions from strangers can be tricky. You do not have to tell everyone your child is adopted. However, if a question comes 	up 	
about differences in appearance or ethnicity, offer a simple but honest explanation. When you are 	proud of your child's identity, 	
she too will learn to appreciate her own value. Be aware that your attitude about adoption will show in your answers. How you	 	
respond can set an example as to how your child may choose to answer these questions in the future	. Also, let your child know 	
that she does not have to give specific answers to strangers if she does not feel comfortable. It is her choice to share what	ever 	
information about her adoption that she chooses. It is fine for children to learn that information	 about their adoption is theirs to 	
share over time. 	 	
The Gift of Each Other	 	
Helping your child accept the fact that she is unique, yet just like everyone else, may not sound easy, but it is important t	o try. 	
Talking openly and truthfully with your child ab	out her history of adoption, her birth parents, and her feelings is the key. Adoption 	
gives both you and your child a tremendous gift	–the gift of each other. With love, honesty, and patience, you and your child will 	
form a relationship that is as deep and 	meaningful as any bond between a parent and child.	 	
  
Source 	 Adoption: Guidelines for Parents (Copyright © 2007 American Academy of Pediatrics, updated 5/07)

5 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
DOCUMENT CHECKLIST	 	
 	
 	Please use this checklist to make sure you have completed all forms and that all documents are available 
PRIOR to scheduling your fingerprint appointment. 	 	
 
 	When applying for a step parent adoption, both the birthparent AND the step parent are considered 
applicants. BOTH must complete all information and provide all requested documents. 	 	
 
__________________________________________________________________________________________	 	
Documents contained in the packet:	 	 
___ 	Application for Adoption	 	
___ Fee Sheet 	Signature Page	 	
___ List of References (with complete addresses, phone numbers and email addresses)	 	
___ Release of Information 	 	
___ Adoption Questionnaire 	 	
_____________________________________________________________________________________________________	_________________________________	 	Documents to collect: 	 	 
___ 	Marriage license	 	
___ Divorce decrees or death certificates for all previous spouses of each applicant	 	
___ 	Birth Certificate for each child being adopted	 (Please bring the original)	 	
 
*If child 	does not have a United States birth certificate then also include a copy of his/her valid, non	-expired legal residency documents. 	
This program is not accredited to perform adoptions of children who are not permanent legal residents of the United States (i	nter	-	
country adoptions).*	 	
 	
___ Legally	-free documentation from each absent parent (	please check appropriate box	):  	
   Consent for Adoption	  	
   Order of Severance/Termination of Parental Rights	  	
   Putative Father Registry Certificate of No File Found	  	
   Death Certificate	 	
 	
___ Picture Identification for each adult applicant	 	
___ Proof of Pima County Residency (current rent receipt, mortgage or utility bill)	 	
___ Legal Residency documentation if either of the applicants is born outside of the United States	 	
___ 	Proof of family income	 (Federal tax forms or W	-2’s for most recent tax year)	  	
Pay earning statements are not sufficient proof of income and cannot be accepted 	 	
___ Fee payment in the amount indicated on the Fee Sheet on Schedule.  Form of payment may be: 	 	
money order, personal check or cashier’s check made payable to: Clerk of The Superior Court.	 	
___ Other__________________________________________________________	_________________________	 	
___ Other___________________________________________________________________________________	 	
___ Other___________________________________________________________________________________

6 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
ADOPTION FEE SHEET	 – Schedule I	 	
 	
Use this	 schedule	 for STEP PARENTS, GRANDPARENTS, GREAT	-GRANDPARENTS, SIBLINGS, or immediate 	
AUNTS and UNCLES to adopt children related by blood, marriage or previous adoption.	 	
 	
 	As required by Pima County Juvenile Court Administrative Order 07	-01, ARS 8	-133 (b) “T	he Pima 	
County Juvenile Court assesses all applicants for adoption for a one	-time fee to cover the cost of the 	
administrative work associated with an adoption.”	 	
 	
 	The Adoption Fee is to cover 	the cost to process	 the application for adoption and 	does not gua	rantee	 	
that adoption will be recommended.  	The fee is non	-refundable	, even if the adoption is delayed or 	
denied, but will be deducted from the Social Study fee if required.	 	
 	
The Adoption fee is $25.00.	 	
 	
 	If a social study is required to complete your adopti	on an additional fee will be required.	  The fee for 	
social study includes services for one subject child and his/her two birthparents. A $30 fee will be 
charged for each additional subject child and each of his/her birthparents if the birthparents are 
diff	erent than those of the first subject child.	 	
The fee is based on the combined gross annual income (before deductions) of the prospective adoptive 
parent(s) and their spouse (in a step	-parent adoption the income if the birth parent who is married to 	
the ste	p-parent is included) for the previous tax year.  	 	
 	
The 	Social Study 	Fee 	is $600.00.	 	
 	
Some families may be eligible for a reduced fee based on the sliding fee scale listed below.	 	
 	
 	
 You may qualify for further fee reduction or fee waiver if your family has a 	financial hardship	. To submit a request for a reduction or waiver, you will need to submit a 	detailed letter explaining your family’s circumstances and a copy of the previous year’s tax return. 	 	
 
 
 
 	
GROSS ANNUAL INCOME AND FEE SCALE	 	
$55,000	-and over...……………$600.00	 	
$50,000	-54,999………………. $500.00	 	
$45,000	-49,999………………. $400.00	 	
$40,000	-44,999………………. $300.00	 	
$35,000	-39,999………………. $200.00	 	
$25,000	-34,999………………. $100.00	 	
$0	-24,999 ……………………. $0.0

7 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 
Application for Adoption Social Study, Certification Home	 Study or Re	-Certification	 	
(Please print or type all information)	 	 	
 
 
1st Applicant	: _________________________   ________________________   _____________________ 	 	
 	 	Last	 	 	 	 	      	First	 	 	 	 	         	Middle	 	
 	
______________________	 	     	__________	 	_________________________	 	
Date of Birth	 	 	 	        	Age	  	 	Social Security Number	 	
 
2nd Applicant	: _________________________   ________________________   _____________________ 	 	
 	 	Last	 	 	 	 	       	First	  	 	 	          	Middle	 	
 
______________________	 	     	__________	 	_________________________	 	
Date of Birth	 	 	 	        	Age	  	 	Social Security Number	 	
 
Relationship to child(ren) being adopted:	 _____________________________________________________________	 	
 
Have you ever applied to be or are you currently a licensed foster pare	nt in Arizona?  _____ No     _____ Yes	 	
 
Have you previously adopted a child OR applied for adoption certification within the last three years in Arizona? 	 	
 
_____ No     _____Yes 	– If yes, please provide the date and file number:	 ___________________________________________	 	
 
 	
Applicant(s) Address and Phone Numbers	 	
 
______________________________________________________________________________________________________	 	
Street Address                                                    	                      	City                                           State                          Zip	 	
 
___________________________	  	___________________________	  	___________________________	  	
Home Phone	 	 	 	 	Cell or Work Phone	  	 	 	Cell or Work Phone	 	
 
 
ADDITIONAL INDIVIDUALS 18 YEARS OF AGE OR OLDER, LIVING IN THE HOME:	 	
 
_______________________________________	 	_________________________	 	____________________________________	 	
Full Name	  	 	 	 	 	Date of Birth	 	 	 	Social Security Number	 	
 
____________________________	___________	 	_________________________	 	____________________________________	 	
Full Name	  	 	 	 	 	Date of Birth	 	 	 	Social Security Number	 	
 
_______________________________________	 	_________________________	 	____________________________________	 	
Full Name	  	 	 	 	 	Date of 	Birth	 	 	 	Social Security Number	 	
 	
 	
I / We verify that the above statement is true and correct to the best of my/our knowledge.	 	
 
___________________________________        ___________________________________________        _____________________ 	 	
Signature                                                                     Printed Name                                   	                                     	 	Date	 	 	
 
___________________________________        ___________________________________________	        	_____________________ 	 	
Signature                                                                     Printed Name                                   	                                     	 	Date

8 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
ADOPTION SOCIAL STUDY FEE	 	
SIGNATURE PAGE	 	
TO BE COMPLETE	D WITH ADOPTIONS PROGRAM STAFF AT FINGERPRINTING APPOINTMENT.	 	
Adoption Fee of $25 paid on _______________________	 	 __________  	 _______	__	_ 	
 	 	 	 	 	Date	 	  	 	  Applicant Initial 	 	 Staff Initial	 	
 	
 
I / We have read the applicable fee schedule and have attached the	 following items:	 	
 1. Money Order or Personal Check in the amount of $ 	25.00	 	
Made payable to:  Clerk of The Superior Court.	 	
 	
 2. Copy of the Applicants’ most recent Federal Tax Return.	 	
           	If married and filing separately, you must include tax forms for each spouse.	 	
 	
If ordered by the court, your social study fee will be:	 	
**	Social Study fee as determined by FEE SCHEDULE   I  	  	 	$ ________________	 	
The social study fee includes serv	ices for one child two birthparents	 	
 	
Additional Child(ren):	    	  $30.00 X __________	 $ ________________	 	
Number of children IN ADDITION to the first child to be adopted	 	
 
Additional birthparent(s):	 	  $30.00 X __________	 $ ________________	 	
To be charged if ad	ditional children have different birth parents	 	
 	
 	 	Minus Adoption Fee	 	 	 	 	  	 	- $25	 	
 	
                                                     	TOTAL SOCIAL STUDY FEE DUE:      	 $ ________________	 	
**This fee will be collected only if a social study is ordered***	 	
I/We understand that the Social Study Fee is to cover 	the cost of the process	 of application for adoption and 	does not 	
guarantee	 that adoption will be recommended.  I/We understand that if a social study is required to complete our 	
adoption an additional fee will be required	.  I/We understand that the fee is non	-refundable, even if the adoption is 	
delayed or denied.	 	
 
______________	_____________________        ____________________________________         ______________ 	 	
Signature                                                                    Printed Name                                    	                            	Date	 	 	
_______	____________________________        ____________________________________         ______________ 	 	
Signature                                                                    Printed Name                                    	                            	Date	 	
___________________________________	        	______________	 	
Signature of Adoptions Program Staff	 	      	Date

9 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
List of References	 	
 
 
First Reference must be a relative of one of the applicants: 	 	
 
1. ______________________________	 	______________________        	___________________________	 	
       First Name	 	 	 	 	 	Middle Name	 	 	 	     Last Name	 	
 
Relationship: ___	_____	__________	_______	    Years Known: _________    	Occupation: ______	___	_______	____________	______	 	
 
Mailing address	: ___________________________________________________________________________	 	
 	 	                	Street (include apt or space #)	 	 	 	City	 	 	State	 	 	Zip Code	 	
 
Phone:	 _______________________	 	 	Phone:	 _______________________	 	
__________________________________________	________________________________________________	 	
 
Additional references cannot be related to either of the applicants and must have known both applicants for two or more years	. 	
 
2. ______________________________	 	______________________        	___________________________	 	
       First Name	 	 	 	 	 	Middle Name	 	 	 	     Last Name	 	
 
Relationship: ___	_____	__________	_______	    Years Known: _________    	Occupation: ______	___	_______	____________	______	 	
 
Mailing address	: __________________________________________	_________________________________	 	
 	 	                	Street (include apt or space #)	 	 	 	City	 	 	State	 	 	Zip Code	 	
 
Phone:	 _______________________	 	 	Phone:	 _______________________	 	
__________________________________________________________________________________________	 	
 
3. ______________________________	 	______________________        ___________________________	 	
       First Name	 	 	 	 	 	Middle Name	 	 	 	     Last Name	 	
 
Relationship: ___	___	____________	_______	    Years Known: _________    	Occupation: ______	___	_______	____________	______	 	
 
Mailing address	: ___________________________________________________________________________	 	
 	 	                	Street (include apt or space #)	 	 	 	City	 	 	State	 	 	Zip Code	 	
 
Phone:	 _______________________	 	 	Phone:	 _______________________	 	
_________________________________________________________________________________________	 	
 
4. ______________________________	 	______________________        ___________________________	 	
       First Name	 	 	 	 	 	Middle Name	 	 	 	     Last Name	 	
 
Relationship: ___	_____	__________	_______	    Years Known: _________    	Occupation: ______	___	_______	____________	______	 	
 
Mailing address	: ______________________________________________________________________	_____	 	
 	 	                	Street (include apt or space #)	 	 	 	City	 	 	State	 	 	Zip Code	 	
 
Phone:	 _______________________	 	 	Phone:	 _______________________

10	 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
                                                                                                                             	                                                      	 	
SUPERIOR COURT OF THE STATE OF ARIZONA	 	
Pima County Juvenile Court	 	
Adoptions 	& Guardianship Program	 	
2225 EAST AJO WAY	 	
TUCSON, ARIZONA 85713	-6295	 	
520	-724	-2920; 520	-724	-9239	 	
FAX 520	-724-4740	 	_________________________________________________________________________________________________________	 	
 
 
 	
Release of Information	 	
 	
I / We ________________________ and ______________________	 	
 
do	 hereby permit the employees of the Pima County Juvenile Court Center 	
Adoptions/Guardianship Program to obtain any and all documents, information 
and inquiries necessary to complete the adoption, certification or guardianship 
review process. (A.R.S 2.8	-112	)  	
 
This consent is valid for six months or the completion of court action, unless 
revoked in writing by the undersigned. 	 	
 
Signed, 	 	
 
______________________________         __________________	 	
Name                                                            	               	Date	 	
 
 
______________________________         __________________	 	
Name                                                                           Date	 	
 
 
 	
 
 	
Veronica Hookland	 	
 Support Staff	 	
 Priscilla Ordonez	 	
  Case Worker

11	 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
ADOPTION QUESTIONNAIRE	 	
Please complete the following as completely and accurately as 	possible	, as it will be included in the legal file	. 	
__________________________________________________________________________________________	 	
 	
Male Applicant	 	
  
Name:	 _______________________________________________	__________	__________   Primary Language: 	_____	_____	_______	 	
             	First	 	 	            	 Middle	 	                    	           	Last	 	               	       	 	  Interpreter needed? _	__ NO     ___YES	 	
 
What is	 your relationship to the child being adopted	:   Birth F	ather	    Step Fath	er   	 Grandfather   	 Uncle   	 Other: 	_______	_________	 	
 
Date	 of birth: _______________________   	Place of bi	rth: _____________________________   	Ethnicity: 	_____________________	 	
 
Phone: _________________________   Phone: ________________________   Social Security	 Number: _______________________	 	
 
Please list any physical health and/or mental health diagnoses and your curren	t treatment: _________________	________________	 	
 ________________________________________________________________________________________________	_______	________________________________	 	 _____________________________________________________________________________________________________________________________	__________	 	
 
Do you have 	any history of substanc	e abuse, including alcohol? If yes, please 	describe, using additional pages if necessary: ________	 	
 _____________________________________________________________________________________________________________________________	__________	 	 ______________________________________________________________	_________________________________________________________________________	 	
 
Have you ever participated in behavioral health services, including counseling or psychia	tric care? Please describe: ___	___________	 	
 ________________________________________________	_______________________________________________________________________________________	 	 _____________________________________________________________________________________________________________________________	__________	 	
 
Have you ever been arrested	 or charged with a crime	 in this or any other state, including traffic violations? _____ NO     _____YES    If 	
YES, please give date, place & explanation, using additional pages if necessary: 	_______________	_____________________________	 	
 __________________	_____________________________________________________________________________________________________________________	 	 _____________________________________________________________________________________________________________________________	__________	 	
 
Have you ever had allegations against you or been investigated by Child Protective Services in this or any other state? 	 	
_____ NO     _____YES     If YES, please give date, place & explanation, using additional pages if necessary: _______________	______	 	
 _______________________________________________________________________________________________________________________________	________	 	 _________________________________________________________________________________________________________________________	______________	 	
 
_______________________________________________________________________________________________________	___	__ 	
 	
Female	 Applicant	 	
 
Name:	 ___________________________________________________________________   Primary Language: _________________	 	
             	First	 	 	   Middle	              	              	Last	 	 	Maiden	       	 	  Interpreter needed? ___ NO     ___YES	 	
 
What is your relationship to the child being adopted:   Birth 	Mo	ther    	Step Mo	ther    	Grandmother	    Aunt	    Other: _______	___	____	 	
 	
Date 	of birth: _______________________   Place of birth: _____________________________   Ethnicity: _____________________	 	
 
Phone: _________________________   Phone: ________________________   Social Security Number: _______________________

12	 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 
 	
(Female applicant 	continued)	 	
 
Please list any physical health and/or mental health diagnoses and your current 	treatment: ___________________	______________	 	
 ____________________________________________________________	___________________________	_______________________________	_________________	 	 _______________________________________________________________________________________	___________________________	_____________________	 	
 
Do you have	 any history of substance abuse, includin	g alcohol? If YES, please describe, using additi	onal pages if necessary: _______	 	
 ____________________________________________________________________________________________________________	___________________________	 	 _____________________________________________________________________________________	_______________________	___________________________	 	
 
Have you ever participated in behavioral health services, including counseling or psychiatric c	are? Please describe: _________	_____	 	
 _________________________________________________________	______________	_____________	___________________________________________________	 	 ____________________________________________________________________________________	___________________________	________________________	 	
 
Have you ever been arrested	 or charged with a crime	 in this or any other state, including traffic violations? _____ NO     _____YES    If 	
YES, please give date, place & explanation, using additional pages if necessary: 	___________________________________________	 	
______________________________________________	______________________________________________________________	___________________________	 	 ____________________________________________________________________________________________________________	___________________________	 	
 
Have you ever had allegations against you or been investigated by Child Protective Services in this or any other state? 	 	
_____ NO     _____YES     If YES, please give date, place & explanation, using additional pages if necessary: __________	___	_______	__ 	
 __________________________________________________	___________________________	__________________________________________________________	 	 _____________________________________________________________________________	___________________________	_______________________________	
____________________________________________________________________________________________________________	 	
 	
Both Applicants	 	
 
Date & location of current marriage: _____________________________________________________________	_________________	 	
 
Home address: _______________________________________________________________________________________________	 	
 	          	   Street	 	                             	Apt #	 	 	 	City	 	 	 	State	 	 	 	Zip Code	 	
 
Do you currently have legal guardianship or 	temporary legal custody of the child(ren) to be adopted?      _____ NO     _____YES    	 	
 
If YES, Where: ______________________________	      	Case Number: ____________________     	Date issued: _________________	 	
 
Has either applicant ever applied to adopt any	 child in the past?	     _____ NO     _____YES   If YES, please explain: 	 	
  _______________________________________	___________________________	_____________________________________________________________________	 	 
 
Has either applicant ever been involved in 	any Adoption, Severance or other Juvenile Court matter	, in any state	?  _____ NO	  ____YES	 	
 
If YES,	 provide case number and explanation: ____	______	____________________________________________________________	 	
 	
 
Has either applicant ever been 	denied	 an adoption or certification in any state?     _____ NO     ____YES 	  If YES	, please explain: 	 	
 __________________________________________________________________________________________________	___________________________	__________	 	
 
Please give the name &	 relationship of whom you have chosen to raise your children in the event of your serious illness or death: 	 	
 ____________________________________________________________________________________________________________	___________________________

13	 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
 	
Please de	scribe why you are applying for adoption, using additional pages if necessary:	 _____________	_______	________	 	
 _____________________________________________________________________________________________________________________________	__________	 	 __________	_____________________________________________________________________________________________________________________________	 	 _____________________________________________________________________________________________________________________________	____	______	 	 
 
Have you talked with your child(ren) about the adoption?  ______YES   ______NO	 	
____________________________________________________________________________________________________________	 	
 	
Information about the child(ren) you wish to adopt	 	
 
First:	 ______________________________   Middle: _________________________   Last: ________________________________	 	
   *Child’s full, legal birth name, as it appear	s on the birth certificate*	 	
 
First: _______________________________   Middle: _____________________	____   Last: ________________________________	 	
    *Proposed Name Change*	 	
 
Date of birth: ______________	___	_______	 Place of birth: _____________________________   Ethnicity: _________	___________	 	
 
When did the child begin living with you? 	_________________________________________________________________________	 	
 
How did the child come into your custody? ________________________________________________________________________	 	
 _________________________________________________________________	____________________________	___________________________	_______________	 	
 
Please list any ph	ysical health and mental health diagnoses for the child and current treatment: 	____________	____________	______	 	
 _______________________________________________________	_____________________________________________________	___________________________	 	
____________________________________________________________________________________________________________	 	
 
First: ______________________________   Middle: _________________	________   Last: _______________________	_________	 	
   *Child’s full, legal birth name, as it app	ears on the birth certificate*	 	
 
First: _______________________________   Middle: _________________________   Last: ________________________________	 	
     	*Proposed Name Change*	 	
 
Date of birth: ________________________	 Place of birth: _____________________________   Ethnicity: _____________________	 	
 
When did the child begin living with you? _______________________________________________________________	__________	 	
 
How did the child come into your custody? ________________________________________________________________________	 	
 _____________________________________________________________________________________	___________________________	________________	_______	 	
 
Please list any physical health and mental health diagnoses for the child and cu	rrent treatment: ______________________________	 	
_____________________________	________________________________________________________________________________________	 	
*Please use additional copies of this page for more children**	 	
 
____________________________________________________________________________________________________________

14	 	
REL	ATIVE ADOPTION Rev. 	3/2014	 	
 	
Birth Par	ent Information 	(NON	-APPLICANT BIRTH PARENTS ONLY)	 	
 
Name of 	Birth M	other	: ______________________________	___	___   	Date of birth o	r approximate age: ____________	___________	 	
 
Last known location: _____________________________________	    Last contact with child: ________	_______	_________________   	 	
 
Last contact with 	applicant(s): _____________________________	_____________________________________________________	_ 	
 
Please list any physical health, mental health & substance abuse issue	s for the birth mother: ______	__________________________	 	
 _____________________________	_____________________________________________________________________	___________________________	__________	 	
 
Name of 	Birth F	ather	: _____	_______________________________   Date of birth 	or approximate age: ___________	_____________	 	
 
Last known location: ______	_______________________________	   Last contact with child: ________________________________   	 	
 
Last contact with applicant(s): ___________________________	_____________________________________________________	___	 	
 
Please list any physical health, mental hea	lth & substance abuse issues for the 	birth father: _____	____________________________	 	
 _____	___________________________	_______________________________________________________________________________________________________	 	
 
Dat	e of severance or consent by 	birth parent(s)	: ___________________	________	__________________	_______________________	 	
 ___	___________________________	_________________________________________________________________________________________________________	 	
_________________________________	___________________________________________________________________________	 	
 	
I / We verify that the information reported in this packet is true and correct to the best of my/our knowledge.  	 	
 _________________________________________________        _____________________________________________________        _______	__________________ 	 	Signature                                                                      	 	                	Printed Name   	                                                                                         	 	   Date	 	 	 _________________________________________________        _____________________________________________________         ______	__________________ 	 	Signature                                                                                                  Printed Name      	                                                                                      	 	    Date
Next: Alaska P-455 Affidavit of Reasonable Investigation Previous: Arizona Consent to Place a Child for Adoption and Waiver of Notice and Appearance
If you want to remove Application for Adoption Social Study, Certification Home Study or Re-Certification and other docs from this website please contact us providing the reasons together with this url: https://formsarchive.com/application-for-adoption-social-study-certification-home-study-or-re-certification-and-other-docs/

Leave a Reply

Your email address will not be published. Required fields are marked *

You can use these HTML tags and attributes <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>