(local form) In the Superior Court of the State of California FOR COURT USE ONLY (RECEIVED ON): In and for the County of Kings ADOPTION QUESTIONNAIRE (for a Stepparent or Domestic Partner Adoption) CASE NUMBER: Instructions to Petitioner: In order to begin the investigation ordered by the Court, you must complete this questionnaire and return it, along with your completed investigation packet to: KINGS COUNTY SUPERIOR COURT 1640 Kings County Drive Hanford, CA 93230 Attention: Adoption Clerk The questionnaire is important in introducing you and your situation to the investigator handling your case. No appointment will be set up to interview you until the form is returned. When returned, you will be contacted by the investigator regarding an office appointment, plans to visit your home and interviewing your children. (Attach additional pages as needed) PETITIONER: Your current name: Other names used: Your current address (Street, City, State and ZIP): Home Telephone: ( ) Business Telephone: ( ) If no home or business telephone, give a contact number where the investigator can reach you: ( ) Name & telephone number of your attorney: ( ) IDENTIFYING DATA OF PETITIONER: Social Security Number: Race: Education: Eye Color: Age: Hair Color: Wgt: Date of Birth: Hgt: Place of Birth: Drivers License/State: Adoption Questionnaire (Stepparent or DP Adoption). Form last revised on 05-04-16 OPTIONAL FORM Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com MARITAL HISTORY OF PETITIONER (List all marriages) Time First Second Third Name of spouse (use maiden names) include present marriage Date of Marriage / / / / / / Date Separated / / / / / / Date & How Terminated Number of Children CHILDREN (List the child/children INVOLVED with this Court action) Name Date of Birth / / / / / / / / / / / / Living with Address Name of other parent CHILDREN (List all your other children NOT INVOLVED in the Court action) Name Date of Birth / / / / / / / / Living with Address Name of other parent Who will provide childcare? Name of caretaker Relationship to children Address Phone Number ( ( EMPLOYMENT Name of Employer (Beginning with your present employment, list employment for the last 5 years) Address of Employer Type of Job Date Begun Date Left / / / / / / / / / / / / / / / / / / / / / / / / Reason for Leaving What period of time ) ) Has child support been paid as ordered? Yes No If "No", amount in arrears: $ MEDICAL HISTORY OF PETITIONER (If either parent or guardian have any physical disability or have received psychiatric treatment or counseling, please complete the section below) Doctor & Address Hospital & Address When Treated Nature of Illness Adoption Questionnaire (Stepparent or DP Adoption). Form last revised on 05-04-16 OPTIONAL FORM Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CRIMINAL RECORD OF PETITIONER: Does petitioner have a criminal history? Yes If "Yes", please give details: No Is petitioner on Probation or Parole? Yes No If "Yes", please give name of Probation Officer or Parole Agent: Area office: ( ) Phone number: ( No ) Does the petitioner have any criminal actions pending: Yes If "Yes, please explain: NATURAL FATHER: Name of natural father: Address: Date of Birth: Employer: Has he consented to Adoption: Yes No Is signed consent filed with the Court: Yes No Place of Birth: Date of last support: Last contact with child? MARITAL HISTORY OF NATURAL FATHER (List all marriages) Time First Second Third Name of spouse (use maiden names) include present marriage Date of Marriage / / / / / / Date Separated / / / / / / Date & How Terminated Number of Children Adoption Questionnaire (Stepparent or DP Adoption). Form last revised on 05-04-16 OPTIONAL FORM Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com NATURAL MOTHER: Name of natural mother (include all names used): Address: Date of Birth: Employer: Has she consented to Adoption: Yes No Is signed consent filed with the Court: Yes No Place of Birth: Date of last support: Last contact with child? MARITAL HISTORY OF NATURAL MOTHER (List all marriages) Time First Second Third Name of spouse (use maiden names) include present marriage Date of Marriage / / / / / / Date Separated / / / / / / Date & How Terminated Number of Children Has there been a prior investigation in another State/County regarding this matter? Yes No Adoption Questionnaire (Stepparent or DP Adoption). Form last revised on 05-04-16 OPTIONAL FORM Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com