Adoption Information Form

Please provide the information requested below. The information requested is necessary to prepare your court documents. Adoptions are very detail oriented. Complete and accurate information is essential. Incomplete, Inaccurate, or inconsistent information will cause delays and additional expenses.

Adoption Information Form

Type of Adoption

Jurisdiction – Choose one of the choices from the pull-down menu

Child / Adoptee

Full Name as Entered on Birth Certificate

If Different, Current Full Name as it Appears on Identification Documents

Full Name as Entered You Wish For It to be Entered on the New Birth Certificate When the Adoption is Completed

Sex

Date of Birth

Estimated due date

Race

Ethnicity

Is the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Hospital name

Hospital address

For infants, date of conception

For infants, place of conception

Citizenship

Has the child ever been the subject of any litigation?

If the child has ever been the subject of any litigation, what type of action:

If you have participated in any litigation concerning the child, or if you have information about a custody proceeding involving the child, provide the following:

If you know of a person who has physical custody or claims to have custody or visitation rights with respect to the child, provide the following:

Provide the following information about where the child has lived during the past five years:

PARENT 1

Biological / Gestational Mother

Full name as entered on birth certificate

If different, current full name as it appears on identification documents

Sex

Date of Birth

Race

Ethnicity

Is the mother of the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply:

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Address

Telephone (Personal)

Email (Personal)

Email (Work)

Education

Occupation

Military Status – Active Duty

Yes

Unknown

If yes, choose one

Army

Navy

Air Force

Marines

Coast Guard

Natinoal Guard - Active Duty

Public Health Service

NOAA

Marital Status

If you are separated from your spouse, list the date of your separation:

If you are divorced or widowed, provide the following information about your former spouse #1:

Place of divorce:

Address of the court:

Name of child’s Birth Parent 2 (Father)

Name of child’s Birth Parent 2 (if more than one possible father)

Name of child’s legal father of child

Parent 2

Legal Father of the Child

Full name as entered on birth certificate

If different, current full name as it appears on identification documents

Sex

Date of Birth

Race

Ethnicity

Is the father of the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply:

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Address

Telephone (Personal)

Email (Personal)

Email (Work)

Education

Occupation

Military Status

Active Duty

Yes

Unknown

If yes, choose one

Army

Navy

Air Force

Marines

Coast Guard

Natinoal Guard - Active Duty

Public Health Service

NOAA

Marital Status

Name of Spouse

If you are divorced or widowed, provide the following information about your former spouse #1:

Place of divorce

Address of the court

Biological Father #1 - If different from the legal father of the child.

Full name as entered on birth certificate

If different, current full name as it appears on identification documents

Sex

Date of Birth

Race

Ethnicity

Is the father of the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Address

Telephone (Personal)

Email (Personal)

Email (Work)

Education

Occupation

Military Status

Active Duty

Yes

Unknown

If yes, choose one

Army

Navy

Air Force

Marines

Coast Guard

Natinoal Guard - Active Duty

Public Health Service

NOAA

Marital Status

Name of Spouse

If you are divorced or widowed, provide the following information about your former spouse #1:

Place of divorce

Address of the court

Biological Father #2 – If more than one possible biological father of the child.

Full name as entered on birth certificate

If different, current full name as it appears on identification documents

Sex

Date of Birth

Race

Ethnicity

Is the father of the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Address

Telephone (Personal)

Email (Personal)

Email (Work)

Education

Occupation

Military Status

Active Duty

Yes

Unknown

If yes, choose one

Army

Navy

Air Force

Marines

Coast Guard

Natinoal Guard - Active Duty

Public Health Service

NOAA

Marital Status

Name of Spouse

If you are separated from your spouse, list the date of your separation

If you are divorced or widowed, provide the following information about your former spouse #1:

Place of divorce

Address of the court

Adoptive Parent 1

Full name as entered on birth certificate

If different, current full name as it appears on identification documents

Sex

Date of Birth

Are you a United States citizen?

What is your immigration status?

If you are a citizen of another country, identify the country:

Is your spouse a United States citizen?

What is your spouse’s immigration status?

If your spouse is a citizen of another country, identify the country:

Race

Ethnicity

Is the father of the child an Alaskan Native or affiliated with a federally recognized Indian tribe?

Yes

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

elibible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Address

Telephone (Personal)

Email (Personal)

Email (Work)

Education

Military Status

Active Duty

Yes

Unknown

If yes, choose one

Army

Navy

Air Force

Marines

Coast Guard

Natinoal Guard - Active Duty

Public Health Service

NOAA

Marital Status

Name of Spouse

If you are separated from your spouse, list the date of your separation:

If you are divorced or widowed, provide the following information about your former spouse #1:

Place of divorce

Address of the court

If you are divorced or widowed, provide the following information about your former spouse #2

Place of divorce

Address of the court

If you are related to the child, identify your relationship to the child

For petitioners adopting an adult (If you are adopting a minor, skip to the next question), identify the following:

Any adult children of the prospective adoptive parent

Any spouse of the prospective adoptive parent

Any parent of the adoptee (adult being adopted)

Any spouse of the adoptee

Any adult child of the adoptee

Text Input

Adoptive Parent 2

Agency

Who prepared your home study?

Agency contact person

Home Study

Placement – If a child was placed with you by an agency

Agency contact person

Postplacement reports

Agency contact person

Adoption Information Form

Type of Adoption

Jurisdiction – Choose one of the choices from the pull-down menu

Child / Adoptee

Provide the following information about where the child has lived during the past five years:

PARENT 1

Biological / Gestational Mother

Parent 2

Legal Father of the Child

Biological Father #1 - If different from the legal father of the child.

Biological Father #2 – If more than one possible biological father of the child.

Adoptive Parent 1

Adoptive Parent 2

Agency

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