PRELIMINARY QUESTIONNAIRE FOR ADOPTIVE PARENTS

PLEASE COMPLETE THE QUESTIONNAIRE BELOW TO HELP US DETERMINE A PROGRAM FOR YOUR PARTICULAR CASE AND TO PROVIDE YOU WITH APPROPRIATE PROGRAM MATERIAL. ALL SUBMITTED INFORMATION IS CONFIDENTIAL AND NOT DISPERSABLE TO ANY THIRD PARTY AND CAN BE REMOVED FROM OUR FILES UPON REQUEST. THIS QUESTIONNAIRE IS NOT AN APPLICATION FOR ADOPTION AND PROCESSING OF REQUESTED INFORMATION IS FREE OF ANY CHARGE OR FURTHER OBLIGATION.

Fields highlighted with asterisks(*) are REQUIRED.

I. PERSONAL DATA

PROSPECTIVE ADOPTIVE MOTHER

*FIRST NAME:

MI:

*LAST NAME:

*AGE:

OCCUPATION:

CITIZENSHIP:

PROSPECTIVE ADOPTIVE FATHER

*FIRST NAME:

MI:

*LAST NAME:

*AGE:

OCCUPATION:

CITIZENSHIP:

*MAILING ADDRESS:

CITY:

STATE: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP CODE:

*E-MAIL:

HOME PHONE NUMBER:

*DAY PHONE NUMBER:

II. PROCESSING INFORMATION

1. *LENGTH OF CURRENT MARRIAGE:	1 - 2 2 - 10 10 - Longer N/A
2. APPRX. FAMILY COMBINED ANNUAL SALARY:	Below - $ 35,000.00 $ 35,000.00 - $ 65,000.00 $ 65,000.00 - $ 99,000.00 $ 99,000.00 - $ 149,000.00 $ 149,000.00 - Above
3. *BIOLOGICAL OR ADOPTED CHILDREN IN YOUR FAMILY, SEX, AGE:	Male Female N/A Male Female N/A
4. OTHERS LIVING IN YOUR HOUSEHOLD:
5. HAS YOUR APPLICATION FOR INTERNATIONAL ADOPTION BEEN DENIED OR WITHDRAWN:	Yes No N/A
6. *CHILD/-REN REQUESTED FOR ADOPTION, AGE MAX:
7. *SEX PREFERENCES, IF ANY:	No Preferences Male Female>
8. WOULD YOU CONSIDER ADOPTING SIBLINGS?:	Yes No Not Sure
9. DESCRIBE YOUR DWELLING AND NEIGHBORHOOD:	Urban Suburban Rural
10. *IF YOU HAVE A SMALL INCOME OR CURRENTLY ARE UNDER FINANCIAL HARDSHIP YOU MAY BE ELIGIBLE FOR OUR "ADOPTION FOR EVERYONE" GRANT. PLEASE BRIEFLY EXPLAIN YOUR FAMILY CIRCUMSTANCES , IF APPLICABLE:
11. *DO YOU HAVE HOME STUDY, IF YES PLEASE PROVIDE THE NAME OF YOUR LOCAL AGENCY:
12. *HAVE YOU SUBMITTED ANY PAPERWORK WITH IMMIGRATION AND NATURALIZATION SERVICES, IF YES WHEN AND WHERE:
13. ANY OTHER ADDITIONAL INFORMATION:

PLEASE SUBMIT REQUESTED INFORMATION BY CLICKING BELOW BUTTON.

THANK YOU FOR SUBMITTING THIS QUESTIONNAIRE!

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