
III. HOUSEHOLD INFORMATION
AD 9 (10/03)
PAGE 6 OF 12
A. CHILD(REN) OF PETITIONER(S)
FULL NAME OF CHILD
DATE OF
BIRTH
EDUCATION
(Name & Address of School & Grade)
HEALTH CONDITIONS
IF ADOPTED
(Place, Date, Agency)
1) Have any of your children ever been arrested for an offense other than a traffic infraction?
■ YES ■ NO
If YES, please explain the charges and any convictions:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
2) Are any of your children currently on probation or parole?
■ YES ■ NO
If YES, please explain the circumstance:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
3) Have any of your adult children ever been investigated for allegations of child neglect or abuse?
■ YES ■ NO
If YES, please explain the circumstances:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4) Have any of your adult children ever been reported for allegations of domestic violence?
■ YES ■ NO
If YES, please explain the circumstances and outcome:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
MAILING ADDRESS CITY, STATE, ZIP
DESCRIBE YOUR HOME (INCLUDE NUMBER OF BEDROOMS & BATHROOMS):
DIRECTIONS TO YOUR HOME:
HAVE YOU EVER HAD ANY PREVIOUS ADOPTIVE PLACEMENT(S)?
■ YES ■ NO IF YES, PLEASE DESCRIBE:
HAVE YOU EVER APPLIED WITH ANOTHER AGENCY?
■ YES ■ NO
IF YES, WHEN AND NAME OF AGENCY:
HOW LONG AT PRESENT ADDRESS
I. CELLULAR PHONE NUMBER
( )
If you are a married or registered domestic couple:
DATE OF MARRIAGE/REGISTRATION:
PLACE OF MARRIAGE/REGISTRATION:
(CITY, COUNTY AND STATE)
If you are an unmarried couple:
LENGTH OF DOMESTIC PARTNERSHIP/RELATIONSHIP:
HAVE YOU FILED A REGISTRATION OF DOMESTIC PARTNERSHIP WITH THE SECRETARY OF STATE?
■ YES ■ NO IF YES, DATE OF FILING:_______________________________________________
II. CELLULAR PHONE NUMBER
( )
HOME TELEPHONE NUMBER
( )