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Questions with an * must be answered. Fill out all possible.

Are you the stepmother or stepfather: *

Stepparent’s full name:

Stepparent’s email address:

Maiden name:

Date of Birth: *

Birth State or Country:

Stepparent’s race:

Religious affiliation:

Social Security Number:

Driver’s License Number:

Were you previously married:

Do you have other minor children:

If yes, how many?

Stepparent’s Present Address Information:

Telephone number:

Present street address: *

What City do you live in: *

What State do you live in: *

What is your Zip Code: *

What County do you live in:

How long have you lived at this address:

How long have you lived in this County:

How long have you lived in this State:

Stepparent's Employer Name

Stepparent’s Employer address:

Stepparent’s job title:

Stepparent’s approximate annual income:

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General Information

Is the mother married to the Stepparent: *

Is the child’s mother deceased: *

Personal Information

First name: *

Middle name:

Last name: *

Maiden name:

Date of Birth:

Birth State or Country:

What is mother’s race:

Religious affiliation:

Social Security Number:

Drivers License Number:

Mother’s Present Address Information:

Telephone number:

Mother’s present street address:

What City does Mother live in:

What State does Mother live in:

What is Mother’s Zip Code:

How long has Mother lived at this address:

How long has Mother lived in this County:

How long has Mother lived in this State:

Present employer Information:

Mother’s employers name:

Mother’s Employers address:

Mother’s job title:

Mother’s approximate annual income:

Is child’s father married to the Stepparent:

Is the child’s father deceased:

Is the father’s identity unknown:

Personal Information

First name:

Middle name:

Last name:

Date of Birth:

Birth State or Country:

What is father’s race:

Religious affiliation:

Social Security Number:

Drivers License Number:

Father’s Present Address Information:

Telephone number:

Father’s present street address:

What City does the father live in:

What State does the father live in:

What is the father’s Zip Code:

How long has father lived at this address:

How long has father lived in this County:

How long has father lived in this State:

Present employer Information:

Father’s employers name:

Father’s job title:

Father’s approximate annual income:

Child’s full legal name: *

Child’s name after adoption: *

Child’s date of birth: *

Child’s age:

Sex of child: *

City where child was born:

State or Country where child was born: *

Child's Hospital of Birth

Date child started residing with Stepparent:

Social Security Number:

Child’s race: *

Is child age 18 or older:

If over 18 and married, name of spouse:

If adoptee is over 18, adoptee's address:

Marriage date between stepparent and spouse:

City and State where marriage took place: *

If Biological Parents Were Married:

Date of Marriage:

Date of Divorce

Was the child conceived through artificial insemination: *

Were the child’s mother and father married to each other at any time: *

Do the natural parents have a court order for custody:

Do the natural parents have a court order for child support:

Was absent parent's parental rights previously terminated by a court order?

Date (or approx. date) parental rights were terminated by court order.

Questions regarding the parent whose rights will be terminated (typically the birth father):

Approximate date the absent parent last paid child support: *

Approximate date the absent parent last had phone contact with the child(ren): *

Approximate date the absent parent last had physical contact with the child(ren): *

Will the absent parent sign a consent to the adoption: *