ADOPTION INFORMATION SHEET SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT DOMESTIC RELATIONS BRANCH – ADOPTION EX PARTE IN THE MATTER OF ADOPTION CASE NO. A- THE PETITION OF JUDGE RONNA LEE BECK FOR ADOPTION OF MINOR CHILD(REN) ADOPTION INFORMATION SHEET 1. Petitioner’s Full Name: 2. Petitioner's Address: 3. Petitioner's Phone Number: 4. Petitioner's Date of Birth: 5. Petitioner's Social Security Number: 6. Petitioner's Driver's License No.: 7. Minor Child's Full Name: 8. Minor Child's Address: 9. Minor Child's Phone No.: 10. Minor Child's Date of Birth: 11. Minor Child's Place of Birth: 12. Minor Child's Social Security Number: 13. Neglect Case Number: 14. Neglect Social File Number: 15. Neglect Judge's Name: 1 Revised 5/15/06 American LegalNet, Inc. www.USCourtForms.com 16. Is the Mother's Affidavit of Paternity attached? Yes or No 17. Has the Mother's Affidavit of Paternity been filed? Yes or No 18. Please provide the case number of the case in which the affidavit was filed: ______________ 19 Mother's Full Name: 20. Mother's Last Known Address: 21. Mother's Phone Number: 22. Mother's Date of Birth: 23. Mother's Social Security No.: 24. Mother's Driver's License No.: 25. Father's Full Name: 26. Father's Last Known Address: 27. Father's Phone Number: 28. Father's Date of Birth: 29. Father's Social Security No.: 30. Father's Driver's License No.: 31. Consent from Mother: Yes or No 32. Consent from Father: Yes or No 33. Relinquishment from Mother: Yes or No 34. Relinquishment from Father: Yes or No 35. Termination of Mother's Parental Rights: Yes or No 36. Termination of Father's Parental Rights: Yes or No 37. Social Worker's Agency: 38. 39. Social Worker's Name: Next Neglect Hearing Date: 2 Revised 5/15/06 American LegalNet, Inc. www.USCourtForms.com 40. 41. Place of Hearing: Courtroom No. Hearing Room No. Petitioner's Counsel's Name: 42. Address: 43. Phone Number: 44. Fax, if any: 45. Email, if any: 46. Petitioner's Additional Contact Information if not Represented by Counsel: 47. Fax, if any: 48. Email, if any: 49. Mother's Counsel's Name: 50. Address: 51. Phone Number: 52. Father's Counsel's Name: 53. Address: 54. Phone Number: 55. Guardian Ad Litem's Name: 56. Address: 57. Phone Number: 58. Petitioner's Relationship to Adoptee: 59. Child has Lived with Petitioner(s) Since: 60. Petitioner's Marital Status: 61. Jurisdiction in Which Petitioner(s) Reside: 62. Competing Case: Yes 63. or No If yes, Competing Case Number: 3 Revised 5/15/06 American LegalNet, Inc. www.USCourtForms.com