ADOPTION QUESTIONNAIRE(If a question is not applicable, please indicate “N/A”)

Full Legal Name, including middle initial __________________________________________________

Known by any other names _____________________________________________________________

d/o/b ___________________ Resident of ___________________________ Alaska since ____________

Mailing Address ______________________________________________________________________

Full Name of Spouse __________________________________________________________________

Date of Marriage _____________________ Location of Marriage ______________________________

Full names of Children (whether or not legitimate), d/o/b____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Have you, your spouse, or any other member of your household been convicted as a sex offender? ____If yes, please explain: __________________________________________________________________ ____________________________________________________________________________________

Is either biological parent of the child to be adopted an Alaska Native or have other Indian blood? _____

If yes, please list Tribal affiliation: _______________________________________________________

Has child been the subject of a case before a Tribal Court? ____________________________________

If yes, please list details ________________________________________________________________

____________________________________________________________________________________

Child to be adopted was born on ______________________, in ________________________________

If you don’t know when the child was born, what information do you have? ______________________

____________________________________________________________________________________

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Name of biological mother of child: ______________________________________________________

Name of biological father of child: _______________________________________________________

Age of biological parents of child: __________________________ __________________________ Mother Father

Has biological parent(s) consented to the adoption? _____________ Please explain ________________

___________________________________________________________________________________

In what ways has the non-custodial biological parent communicated with the child in the previous year? Please give details of visits, cards, gifts, phone calls, etc. ______________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Child’s current full name: ______________________________________________________________

Child’s name after adoption: ____________________________________________________________

Do you have an original birth certificate? __________________________________________________

Child lived in your home since: __________________________________________________________

Who else has lived with the child while with you? ___________________________________________

List prior residences of child for the past five years as follows:Dates Place Child Lived Person Child Lived With

(month & year) (city & state) (name & current address)

______ to ______ __________________________ ____________________________________

______ to ______ __________________________ ____________________________________

______ to ______ __________________________ ____________________________________

______ to ______ __________________________ ____________________________________

______ to ______ __________________________ ____________________________________

Visitation proposed? ________________ If yes, list proposed visitation schedule __________________

What steps has the custodial parent taken to foster the relationship with the non-custodial natural parent?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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What action has the custodial natural parent taken to discourage the relationship with the non-custodial natural parent? _______________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What steps has the stepparent taken to foster the relationship with the non-custodial natural parent?

____________________________________________________________________________________

____________________________________________________________________________________

What steps has the stepparent taken to discourage the relationship with the non-custodial natural parent?

____________________________________________________________________________________

____________________________________________________________________________________

Have you participated as a party, a witness or in another capacity in other litigation concerning the custody of this child in Alaska or in another state? _________________________ If yes, give details.

____________________________________________________________________________________

____________________________________________________________________________________

Do you have further information of another custody proceeding concerning this child now pending in a court in Alaska or in another state or tribal court? _________________________ If yes, give details.

____________________________________________________________________________________

____________________________________________________________________________________

Do know of a person not a party to this proceeding who has physical custody of this child or claims to have custody or visitation rights? _________________________ If yes, give details.

____________________________________________________________________________________

Please list the adoptive child’s property:

Description Value

_________________________________________________ $______________________________________________________________________________ $______________________________________________________________________________ $______________________________________________________________________________ $______________________________________________________________________________ $_____________________________

Do you have any specific concerns or expect any specific complications in connection with the filing of your adoption petition? Please list: _______________________________________________________

____________________________________________________________________________________

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