SUPERIOR COURT OF CALIFORNIA COUNTY OF MARIN Probate Court Investigations 3501 Civic Center Drive, Room 116 P.O. Box 4988 San Rafael, CA 94913 (415) 444-7090 STEPPARENT ADOPTION QUESTIONNAIRE DATE: _______________________ CASE NUMBER: ALL ANSWERS ARE TO BE GIVEN UNDER PENALTY OF PERJURY All questions must be answered for a report to be filed with the Court. This information will be held confidential. Please return the questionnaire to the address above. PART I - MINOR(S) TO BE ADOPTED 1. Full Name (before adoption): Age: _________ Date of Birth: ____________ Name of School and/or Day Care Provider: Address: Telephone No(s): Grade: Yes No Does the child have any learning difficulties or an Individual Educational Plan (IEP)? If yes, please explain Does the child have any developmental disabilities or delays? Yes No If yes, please explain If yes, is the child a client of the Golden Gate Regional Center? Yes No Does the child have any health problems? Yes No If yes, please explain Name of Doctor: Names of Regular Medications: Is the child in therapy or counseling? Yes No If yes, Name of Counselor: Telephone No: Has the child been the subject of a step-parent adoption before? Yes No If yes, provide information about the case: 2. Full Name (before adoption): Age: _________ Date of Birth: ____________ Name of School and/or Day Care Provider: Address: Telephone No(s): PR021 (Rev. 12/09) STEPPARENT ADOPTION QUESTIONNAIRE (Optional Form) Telephone No: Grade: Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com PART I - MINOR(S) TO BE ADOPTED cont'd Does the child have any learning difficulties or an Individual Educational Plan (IEP)? If yes, please explain Does the child have any developmental disabilities or delays? Yes No If yes, please explain If yes, is the child a client of the Golden Gate Regional Center? Yes No Does the child have any health problems? Yes No If yes, please explain Name of Doctor: Names of Regular Medications: Is the child in therapy or counseling? Yes No If yes, Name of Counselor: Telephone No: Has the child been the subject of a step-parent adoption before? Yes No If yes, provide information about the case: Telephone No: Yes No If the adoption is for more than two children, please include an additional page for each child. PART II - PARENT WHO HAS CUSTODY OF MINOR(S) Full Name: Birthdate: Address: Home No.: Employer's Name: Employer's Address: Occupation: Gross Monthly Salary: Were the natural parents married to each other? Length of Employment: Amount of other income, if any: No (If no, please answer "A" questions below) Yes (If yes, please answer "B" questions below) A. Did the natural parents live together at the time the child was conceived? If yes, how long did they live together? B. Date natural parents were married: City and state where natural parents were married: How marriage terminated: Date marriage was terminated: City and state where marriage was terminated: If divorced, who was awarded custody? PR021 (Rev. 12/09) STEPPARENT ADOPTION QUESTIONNAIRE (Optional Form) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Birthplace: Work No.: Cell No.: Yes No PART II - PARENT WHO HAS CUSTODY OF MINOR(S) cont'd Prior Marriages/Domestic Partner Registrations: Name Date Place Date Terminated PART III - ABSENT PARENT Full Name: Address: Home No.: Employer's Name: Has this parent consented to this adoption? Yes No Work No.: Cell No.: Occupation: When did the absent parent last contribute to the support of the child(ren)? How much? PART IV - PETITIONER Full Name: Address: Home No.: Birthdate: Length of time at current address: Work No.: Birthplace: Own or Rent? Cell No.: Length of residence in Marin County: ______________ Length of residence in California: Employer's Name: Employer's Address: Occupation: Prior Marriages/Domestic Partner Registrations: Name Date Place Date Terminated Length of Employment: Telephone No.: Children from Current Marriage/Domestic Partner Registration: Name Age PR021 (Rev. 12/09) STEPPARENT ADOPTION QUESTIONNAIRE (Optional Form) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com PART IV - PETITIONER cont'd Children Residing in the Home: Name Age Names of others residing in the home: Military Service: Branch: Type of Discharge: Do you have a criminal record? No Date Entered: Yes Date Discharged: List any arrests for which you were booked and disposition of case (do not include vehicle citations): Are you currently on parole? Probation? If yes, give the name, address and phone number of your Supervising Officer: PR021 (Rev. 12/09) STEPPARENT ADOPTION QUESTIONNAIRE (Optional Form) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com PETITIONER'S FINANCIAL INFORMATION MONTHLY EXPENSES/PAYMENTS: Rent/Mortgage: Utilities: Transportation: Clothing for _____ persons: Food for _____ persons: Spousal Support: Child Support: Health Insurance: Life Insurance: CREDITORS: REAL ESTATE: Market Value: Equity: AUTOMOBILES: Make: Make: BANK ACCOUNTS: Checking Account Balance: Savings Account Balance: Investments Balance: Equity: Equity: SPOUSE/PARTNER: Gross Wages: Balance Payment MONTHLY INCOME/PROPERTY VALUES: Gross Wages: Spousal Support: Child Support: Unemployment: Public Assistance (welfare/food stamps): Other - specify (i.e., Social Security, Rental Income, Pension) I CERTIFY THAT THE ABOVE IS A FULL AND CORRECT STATEMENT OF MY FINANCIAL STATUS TO THE BEST OF MY KNOWLEDGE AND BELIEF. DATE SIGNATURE PR021 (Rev. 12/09) STEPPARENT ADOPTION QUESTIONNAIRE (Optional Form) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com