OAKLAND COUNTY CIRCUIT COURT- FAMILY DIVISION, ADOPTION SERVICES ADOPTION QUESTIONNAIRE ­ ADULT Name of Adult Adoptee First Middle Middle Middle Last Last Last Maiden Name, if Married First Name After Adoption First Date of Birth Present Address No. Street City State Zip Code Phone Number (Home) (Cell) (Work) THE MICHIGAN ADOPTION CODE REQUIRES BIRTH PARENTS TO RECEIVE A NOTICE OF ADOPTION. Please give the following information about them: Birth Father's Name First Middle Street Middle Last City Last State Zip Code Date of Birth Present / Last Known Address No. Birth Mother's Name First Date of Birth Present/ Last Known Address No. Street City State Zip Code Name of Proposed Adoptive Father First Middle Last Date of Birth Present Address No. Street City State Zip Code Phone Number (Home) (Cell) (Work) Name of Proposed Adoptive Mother First Middle Last Date of Birth Present Address No. Street City State Zip Code Phone Number (Home) (Cell) (Work) Brief reason for adoption Have proposed adoptive parents ever been convicted in a criminal proceeding, imprisoned, placed on probation or parole (including DUI)? Yes No If yes, give details including date, place, nature of offense and disposition I have examined this adoption questionnaire and the contents are true. Signature of Proposed Adoptive Mother Date Signature of Proposed Adoptive Father Adult Questionnaire.doc Rev. 2.2014 American LegalNet, Inc. www.FormsWorkFlow.com