FOR COURT USE ONLY (RECEIVED ON): In the Superior Court of the State of California In and for the County of Sacramento ADOPTION QUESTIONNAIRE (for a Stepparent or Domestic Partner Adoption) Case Name: CASE NUMBER: Instructions to Petitioner: In order to schedule a hearing date and begin the investigation ordered by the Court, you must complete this questionnaire and provide copies of the required documents as indicated to: SACRAMENTO COUNTY SUPERIOR COURT 3341 Power Inn Road, Family Law Sacramento, CA 95826 The questionnaire is important in introducing you and your situation to the investigator handling your case. Attach all additional documents as applicable to this questionnaire. The court will not file an incomplete packet or schedule a hearing date until all of the necessary forms are completed and submitted to the court. PETITIONER: Your current name: Driver’s License No. Maiden name and/or any other names used: Name & telephone number of your attorney: ( ) Your current address (Street, City, State and ZIP): How long at this address? Home Telephone: ( Years Months ) Business Telephone: ( ) If no home or business telephone, give a contact number where the investigator can reach you: ( ) IDENTIFYING DATA OF PETITIONER: Social Security Number: Race: Eye Color: Age: Hair Color: Date of Birth: Wgt: Place of Birth: Hgt: Extent of schooling, H.S./College, etc. Insurance (Life, Health, car, etc.) specify: FL/E-LP-647 (adopted 6/10) Mandatory Adoption Questionnaire Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com MARITAL HISTORY OF PETITIONER (List all marriages) Name of spouse (use maiden names) include present marriage Time Date of Marriage Date & How Terminated Date Separated First / / / / Second / / / / Third / / / Number of Children / **Attach a certified copy of the current marriage license or Certificate of Registered Domestic Partnership** **If applicable, attach a certified copy of the final divorce judgment of each previous marriage** CHILD (List the child INVOLVED with this Court action) Name Date of Birth / Living with Address Name of other parent Indian Ancestry? yes / Has the child ever been involved in any another court case? Yes no No If so, what county ________________, case number _____________________. **Attach certified copy of the birth certificate** **If applicable, attach a certified copy of the Order of Adoption, if the minor has been previously adopted** **If applicable, attach a certified copy of the most recent court order awarding custody of the child to be adopted or an Order Terminating Parental Rights or Order Declaring Minor Free from Parental Custody and Control** **If applicable, attach a certified copy of any orders changing name** CHILDREN (List all your other children NOT INVOLVED in the Court action) Name Date of Birth / / / Name of other parent / / Address / / Living with / Since the separation of the parents of the minor(s), whom have the children been living with? Also list dates: HEALTH OF CHILDREN (List each child in this case who has recently been under the care of a Doctor, or Psychiatrist, including family physician) Child Doctor Address Date / / / Adoption Questionnaire / / FL/E-LP-647 (adopted 6/10) Mandatory / / Reason / Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Do any of the children presently have physical or mental problems? Yes No Please explain: Plan of custody/visitation: Place of residence for self and children: Will children be placed under supervision of others? Name of caretaker Relationship Address Phone Number What period of time to children ( ) ( ) State the reasons why you feel the other parent should not have custody/visitation and be specific. Give examples and dates (attach additional sheet, if needed). 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 / Current working hours and days: MONTHLY INCOME Gross Net From employment $ $ Own business $ $ Public Assistance (AFDC or Social Security Assistance) $ $ Child support $ $ Other sources $ $ $ $ TOTAL Does the petitioner pay child support? Yes If yes, is the amount in the arrears? Yes FL/E-LP-647 (adopted 6/10) Mandatory No No If yes, amount in arrears $_________ Adoption Questionnaire Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 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 CRIMINAL RECORD OF PETITIONER: Does petitioner have a criminal record? Yes No If “Yes”, please give details: Is petitioner on Probation or Parole? Yes No If “Yes”, please give name of Probation Officer or Parole Agent: Area office: ( ) Phone number: ( Does the petitioner have any criminal actions pending: Yes ) No If “Yes, please explain: FL/E-LP-647 (adopted 6/10) Mandatory Adoption Questionnaire Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com NATURAL FATHER: Name of natural father: Date of last support: Address: Last contact with child? Place of Birth: Date of Birth: Race: Employer: Occupation: Has he consented to Adoption: Yes No Date of last contact with any other relative? **If applicable, attach a certified copy of the death certificate, proof of parental rights being terminated, or orders changing name ** MARITAL HISTORY OF NATURAL FATHER (List all marriages) Time Name of spouse (use maiden names) include present marriage Date of Marriage Date Separated First / / / / / / / Third / / / Number of Children / Second Date & How Terminated / Is the child a result of a donorship? Yes No Adoption Questionnaire (Stepparent or DP Adoption). Is yes, attach proof of donorship. Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com NATURAL MOTHER: Name of natural mother (include all names used): Date of last support: Address: Last contact with child? Place of Birth: Date of Birth: Race: Employer: Occupation: Has she consented to Adoption: Yes No Date of last contact with any other relative? **If applicable, attach a certified copy of the death certificate, proof of parental rights being terminated, or any orders changing name** MARITAL HISTORY OF NATURAL MOTHER (List all marriages) Time Name of spouse (use maiden names) include present marriage Date of Marriage Date Separated First / / / / / / / Third / / / Number of Children / Second Date & How Terminated / **Before submitting your documents to the court, confirm that you have you attached all required documents to this packet?** Adoption Questionnaire (Stepparent or DP Adoption). Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com