STATE OF MAINE DISTRICT COURT Location Docket No. In re the Adoption of: (Name of Minor Adoptee) CONFIDENTIAL STATEMENT TO ACCOMPANY PETITION FOR ADOPTION Have you ever adopted another child? How many? 3. Are there other children in your home now? How many? Their ages? 4. Are you legally responsible for any children not living in your home? How many? 5. If you are responsible for any child support payments, are you current in those payments? 6. Has an action to remove a child from your custody ever been brought against you? 7. What is your current occupation? How long have you had it? 8. What is your current annual salary? 9. What is your approximate net worth? 10. Do you own or rent your home? How long have you lived there? 11. If you rent, what is your monthly rent payment? 12. If you own, what is your monthly mortgage payment? 13. If you own your home, what is it worth, and how much, if any, is the mortgage on it? 14. Do you have any chronic infectious or congenital disease (that you are willing to disclose)? AD-006, Rev. 07/16 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 15. Have you ever been convicted of a crime punishable by a term of one year or more of imprisonment? 16. Have you ever been convicted of a crime of violence? 17. Have you ever had a Protection from Abuse or Protection from Harassment order against you? 18. Are there any criminal or civil charges pending against you in any court? 19. What is the highest grade from which you graduated in school? 20. Are you currently involved in a bankruptcy or insolvency proceeding in which your debts to others may be affected? 21. What is your current mailing address? 22. List any other legal residences you had during the past five years. 23. List your current employer's name and address. 24. List the name(s) and address(es) of your employers during the past five years. 25. How many times have you been married? 26. Were you divorced from your last spouse? If so, attach the divorce decree. AD-006, Rev. 07/16 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 27. If you are married, when did you marry your current spouse? 28. If you are not married, how long have you been living with your partner? 29. Have you ever had an application to adopt a child denied by a court or a public or private agency? Add here any explanation of any one of the foregoing answers that you wish to explain to the court and any other information that you feel may assist the court in determining whether it should grant this adoption. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Dated: Petitioner (Adopting parent 1) Dated: Petitioner (Adopting parent 2) AD-006, Rev. 07/16 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com