Questionnaire AdminHome

Please fill in the answers to each question below. PLEASE TRY TO ANSWER EVERY QUESTION.

Are you the adopting mother or father: *

Adopting Father

Your full legal name:

Larry Jehorek

Your email address:

lj_76@yahoo.com

Maiden name:

jehorek

Date of Birth: *

12-17-1976

Birth State or Country:

Missouri

Stepparent’s race:

Caucasian

Religious affiliation:

Social Security Number:

494786259

Driver’s License Number:

M206275021

Were you previously married:

No

Do you have other minor children:

Yes

If yes, how many?

2

Your Present Address Information:

Telephone number:

8162056111

Present street address: *

2910 morningside dr

What City do you live in: *

saint joseph

What State do you live in: *

Missouri

What is your Zip Code: *

64503

What County do you live in:

Buchanan

How long have you lived at this address:

1 month

How long have you lived in this County:

43 years

How long have you lived in this State:

43 years

Your Employer Name

Ring Container

Your Employer's full address:

1 Ring Container Saint Joseph Mo 64503

Your job title:

Machine Operator

Your approximate annual income:

41,600

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PLEASE TRY TO ANSWER EVERY QUESTION.

Is the mother married to the Adopting Parent: *

Yes

Is the child’s mother deceased: *

No

Personal Information - Answer ALL questions

First name: *

Brittany

Middle name:

Jenell

Last name: *

Jehorek

Maiden name:

Baker

Date of Birth:

7-17-1987

Birth State or Country:

Missouri

What is mother’s race:

Caucasian

Religious affiliation:

Social Security Number:

494942826

Drivers License Number:

N206198005

Mother’s Present Address Information:

Telephone number:

8162056471

Mother’s present street address:

2910 Morningside Dr

What City does Mother live in:

Saint Joseph

What State does Mother live in:

Missouri

What is Mother’s Zip Code:

64503

How long has Mother lived at this address:

1 month

How long has Mother lived in this County:

32 years

How long has Mother lived in this State:

32 years

Present employer Information:

Mother’s employers name:

St Jo Frontier Casino

Mother’s Employers address:

777 Winners Circle Saint Joseph MO 64505

Mother’s job title:

Facilities Coordinator

Mother’s approximate annual income:

27500

Is child’s father married to the Adopting Parent:

No

Is the child’s father deceased:

No

Is the father’s identity unknown:

No

Personal Information-FILL IN EVEN if this is an adult adoption or the father is deceased.

First name:

Adam

Middle name:

Lee

Last name:

Clark

Date of Birth:

6-14-1980

Birth State or Country:

Missouri

What is father’s race:

Caucasian

Religious affiliation:

Social Security Number:

Unkown

Drivers License Number:

Unkown

Father’s Present Address Information:

Telephone number:

5732187100

Father’s present street address:

1012 West Columbia

What City does the father live in:

Farmington

What State does the father live in:

Missouri

What is the father’s Zip Code:

63640

How long has father lived at this address:

Unkown

How long has father lived in this County:

Unkown

How long has father lived in this State:

39 years

Present employer Information:

Father’s employers name:

Not employed

Father’s job title:

N/a

Father’s approximate annual income:

N/a

Child’s full legal name: *

Gaige Allen Lee Clark

Child’s name after adoption: *

Gaige Allen Jehorek

Child’s date of birth: *

8-2-06

Child’s age:

13

Sex of child: *

Male

City where child was born:

Saint Joseph

State or Country where child was born: *

Missouri

Child's Hospital of Birth

Heartland Health

Date child started residing with Adopting Parent:

June 2008

Social Security Number:

486251076

Child’s race: *

Caucasian

Is child age 18 or older:

No

If over 18 and married, name of spouse:

N/a

If adoptee is over 18, adoptee's address:

N/a

Marriage date between stepparent and spouse:

5-12-2010

City and State where marriage took place: *

Saint Joseph, MO

If Biological Parents Were Married:

Date of Marriage:

N/a

Date of Divorce

N/a

Was the child conceived through artificial insemination: *

No

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

No

Do the natural parents have a court order for custody:

No

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

Yes

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

No

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

N/a

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

Approximate date the absent parent last paid child support: *

Many years ago

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

6/2007

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

6/2007

Will the absent parent be signing a consent to the adoption which will be filed with the Court: *

Unknown