Oakland County Circuit Court ­ Family Division, Adoption Services Adoption Questionnaire - Relatives Name of child(ren) First First Name after adoption First First Name of Proposed Adoptive Father First Date of birth Present address No. How long have you lived at present address? Email Street City Home Phone Cell Phone Work Phone Employer's Name If self-employed, name and type of business If unemployed, source of income Name of Proposed Adoptive Mother First Date of Birth Present Address No. How long have you lived at present address? Email Street City Home Phone Cell Phone Work Phone Employer's Name If self-employed, name and type of business If unemployed, source of income How are you related to the child(ren)? Occupation State Zip Code Middle Last Occupation State Zip Code Middle Last Middle Middle Last Last Middle Middle Last Last Date of Birth Date of Birth Adoption Questionnaire - Relative Page 1 American LegalNet, Inc. www.FormsWorkFlow.com February 2014 What is the reason for adoption? Do you have a guardianship? Birth Father's Name First Present / Last Known Address Yes No If yes, where? Case Number? Last (attach letters of guardianship, if not Oakland) Date of Birth Middle No. Street City Date of Birth State Zip Driver's License No. Birth Mother's Name First Present / Last Known Address No. Driver's License No. Has the father's paternity been established through Court proceedings? Are children's parents married? Yes No Circuit Court Middle Street Last City State Zip Probate Court No Divorced Have the parents of this child or proposed adoptive parents had any contact with Children's Protective Services? Yes No If yes, name of Children's Protective Services caseworker Phone Have proposed adoptive parents ever been convicted in a criminal proceeding, imprisoned, placed on probation or parole, (including Yes No DUI)? If yes, give details including date, place, nature of offense and disposition I have examined this adoption questionnaire and its contents are true to the best of my information, knowledge, and belief. Date Signature of Proposed Adoptive Mother Date Signature of Proposed Adoptive Father REFERENCES Please list individuals you have known for several years who know you well enough, whom we can contact to write a letter to the Court on your behalf: PLEASE NO RELATIVES 1. Name Address No. 2. Name Address No. 3. Name Address No. Street City State Zip Code Street City Phone State Zip Code Street City Phone State Zip Code Phone Adoption Questionnaire - Relative Page 2 American LegalNet, Inc. www.FormsWorkFlow.com February 2014