Adoption Information Form

1. Type of Adoption

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

3. Child / Adoptee

Full name as entered on birth certificate

First

Middle

Maiden

Last

Page 1

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

First

Middle

Maiden

Last

Full name as you wish for it to be entered on the new birth certificate when the adoption is completed

First

Middle

Maiden

Last

Sex

Date of Birth

Estimated due date

Race

Ethnicity

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

Yes

No

Tribe Name

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

eligible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Page 2

Place of birth

City

County

State

Country

Hospital name

Hospital address

Street

City

County

State

Zip Code

Country

For infants, date of conception

For infants, place of conception

City

County

State

Country

Citizenship

Is the child a United States citizen?

If the child is a citizen of another country, identify the country:

What is the child’s immigration status?

Has the child ever been the subject of any litigation?

Page 3

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:

Name of the court

Address of the court

Street

City

County

State

Zip Code

Country

File number

Your capacity as a participant

Date of the custody determination

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:

Name

Page 4

Details (eg. Joint custody, sole custody, visitation, etc. )

Current Address

Type of custody claim

4. Provide the following information about where the child has lived during the past ten years:

From

To (Current date )

Current Address

Person(s) Lived with

Current Address of Person

Page 5

PARENT 1

5. Biological / Gestational / Presumed Mother

Full name as entered on birth certificate

First

Middle

Maiden

Last

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

First

Middle

Maiden

Last

Sex

Date of Birth

Race

Ethnicity

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

Yes

No

Tribe Name

If yes, mark all that apply:

member of an Indian tribe

biological child of a member of an Indian tribe

eligible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Page 6

Place of birth

City

County

State

Country

Current Address

Street

City

County

State

Zip Code

Country

Telephone (Personal)

Email (Personal)

Email (Work)

Citizenship

Are you a United States citizen?

What is your immigration status?

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

Page 7

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Marital Status

Place of Marriage

City

County

State

Country

Date of Marriage

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

Page 8

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

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Current Address

City

State

County

Country

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina):

File number

Name of child’s birth parent 2 (father)

First

Middle

Last

Name of child’s birth parent 2 (if more than one possible father)

First

Middle

Last

Name of child’s legal father of child

First

Middle

Last

Page 9

Parent 2

6. Legal / Presumed Father of the Child

Full name as entered on birth certificate

First

Middle

Last

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

First

Middle

Last

Sex

Date of Birth

Race

If yes, mark all that apply:

member of an Indian tribe

biological child of a member of an Indian tribe

eligible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Current Address

Street

City

County

State

Zip Code

Country

Page 10

Telephone (Personal)

Email (Personal)

Email (Work)

Citizenship

Are you a United States citizen?

What is your immigration status?

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

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Marital Status

Date of Marriage

Place of Marriage

City

County

State

Country

Page 11

Name of Spouse

First

Middle

Last

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:

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina)

Address of the court

Street

City

County

State

Zip Code

Country

File number

Page 12

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

Full name as entered on birth certificate

First

Middle

Last

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

First

Middle

Last

Sex

Date of Birth

Race

Ethnicity

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

Yes

No

Tribe Name

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

eligible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Place of birth

Current Address

Street

City

County

State

Zip Code

Country

Telephone (Personal)

Page 13

Email (Personal)

Email (Work)

Citizenship

Are you a United States citizen?

What is your immigration status?

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

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Marital Status

Date of Marriage

Page 14

Place of Marriage

Name of Spouse

First

Middle

Last

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:

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina)

Address of the court

Street

City

County

State

Zip Code

Country

File number

Page 15

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

Full name as entered on birth certificate

First

Middle

Last

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

First

Middle

Last

Sex

Date of Birth

Race

Ethnicity

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

Yes

No

Tribe Name

If yes, mark all that apply

member of an Indian tribe

biological child of a member of an Indian tribe

eligible for membership in an Indian tribe

ever live on a reservation

claim tribal heritage

Tribe(s)

Page 16

Place of birth

Current Address

Street

City

County

State

Zip Code

Country

Telephone (Personal)

Email (Personal)

Email (Work)

Citizenship

Are you a United States citizen?

What is your immigration status?

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

Page 17

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Page 18

Marital Status

Date of Marriage

Place of Marriage

Name of Spouse

First

Middle

Last

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:

First

Middle

Maiden

Last

Page 19

Date of marriage

Date of Death

Date of divorce

Place of divorce

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina)

Address of the court

Street

City

County

State

Zip Code

Country

File number

Page 20

Adoptive Parent 1

9. Adoptive Parent 1

Full name as entered on birth certificate

First

Middle

Maiden

Last

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

First

Middle

Maiden

Last

Sex

Race

Ethnicity

Page 21

Date of Birth

Place of birth

Current Address

Street

City

County

State

Zip Code

Country

Telephone (Personal)

Email (Personal)

Email (Work)

Citizenship

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:

Page 22

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Marital Status

Page 23

Name of Spouse

First

Middle

Last

Date of marriage

Place of Marriage

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:

First

Middle

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

Page 24

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina)

Address of the court

Street

City

County

State

Zip Code

Country

File number

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

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina)

Page 25

Address of the court

Street

City

County

State

Zip Code

Country

File number

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

Relation to Adoptive Parent

Name - First / Middle / Maiden / Last

Current Address

Address

Age

Relation to Adult Adoptee

Name

Current Address

Address

Age

Page 26

Adoptive Parent 2

10. Adoptive Parent 2

Full name as entered on birth certificate

First

Middle

Maiden

Last

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

First

Middle

Maiden

Last

Sex

Race

Ethnicity

Date of Birth

Place of birth

City

County

State

Country

Page 27

Current Address

Street

City

County

State

Zip Code

Country

Telephone (Personal)

Email (Personal)

Email (Work)

Citizenship

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:

Page 28

Education

Highest Grade Completed

GED

Tech / Vocational School

College

Occupation

Military Status – Active Duty

Yes

No

Unknown

Marital Status

Name of Spouse

First

Middle

Last

Page 29

Date of Marriage

Place of Marriage

City

County

State

Country

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

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

City

County

State

Country

Page 30

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina):

Address of the court

Street

City

County

State

Zip Code

Country

File number

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

First

Middle

Maiden

Last

Date of marriage

Date of Death

Date of divorce

Place of divorce

City

County

State

Country

Page 31

Name of the court entering the divorce decree or judgment (ie. District Court, 10th Judicial District, Wake County, North Carolina):

Address of the court

Street

City

County

State

Zip Code

Country

File number

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

Relation to Adoptive Parent

Name - First / Middle / Maiden / Last

Current Address

Address

Age

Relation to Adult Adoptee

Name

Current Address

Address

Age

Page 32

Agency

11. Agency

Who prepared your home study?

Agency Name

Agency Address

Agency contact person

Name

Email address

Telephone

Home Study

Date completed

Date update 1

Date update 2

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

Date of placement

Agency Name

Agency Address

Page 33

Agency contact person

Name

Telephone

Email address

Postplacement reports

Date of postplacement report #1

Date of postplacement report #2

Other

Agency Name

Agency Address

Agency contact person

Name

Telephone

Email address

All Forms

Adoption Information Form

1. Type of Adoption

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

3. Child / Adoptee

4. Provide the following information about where the child has lived during the past ten years:

PARENT 1

5. Biological / Gestational / Presumed Mother

Parent 2

6. Legal / Presumed Father of the Child

Adoptive Parent 1

9. Adoptive Parent 1

Adoptive Parent 2

10. Adoptive Parent 2

Agency

11. Agency

Call Request Form

PPC Page

Main Contact Form

All Forms

Adoption Information Form

1. Type of Adoption

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

3. Child / Adoptee

4. Provide the following information about where the child has lived during the past ten years:

PARENT 1

5. Biological / Gestational / Presumed Mother

Parent 2

6. Legal / Presumed Father of the Child

Adoptive Parent 1

9. Adoptive Parent 1

Adoptive Parent 2

10. Adoptive Parent 2

Agency

11. Agency

Call Request Form

PPC Page

Main Contact Form

Pease Enter your Number For Callback