OAKLAND COUNTY CIRCUIT COURT - FAMILY DIVISION, ADOPTION SERVICES ADOPTION QUESTIONNAIRE ­ STEPPARENTS Name of Child(ren) First First Middle Middle Middle Middle Last Last Last Last Date of Birth Date of Birth Name After Adoption First First Name of Proposed Adoptive Mother or Father First Middle Last Date of birth Present address No. Street City State Zip Code How long have you lived at present address? E-MAIL ________________________________________________ Home Phone Cell Phone Work Phone Employer's Name If self-employed, name and type of business If unemployed, source of income Occupation *PLEASE COMPLETE EVEN IF YOU ARE BIRTH PARENT* Name of Custodial Birth Parent First Middle Last Date of birth Present address No. Street City State Zip Code How long have you lived at present address? E-MAIL _____________________________________________________ Home Phone Cell Phone Work Phone Employer's Name Occupation If self-employed, name and type of business If unemployed, source of income American LegalNet, Inc. www.FormsWorkFlow.com Birth Father's Name First Middle Last Date of birth Present / last known address No. Street City State Zip Code Driver's License No. Birth Mother's Name First Middle Last Date of birth Present / last known address No. Street City State Zip Code Driver's License No. Date stepparent and child(ren) began living together Brief reason for stepparent to adopt REFERENCES: Please list individuals you have known for several years who know you well enough as a family to write a letter to the Court on your behalf: NO RELATIVES 1. Name Address No. Street City State Zip Code Phone 2. Name Address No. Street City Phone State Zip Code 3. Name Address No. Street City Phone State Zip Code 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 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 Custodial Parent Date Signature of Proposed Adoptive Parent Stepparent Questionnaire.doc American LegalNet, Inc. www.FormsWorkFlow.com Rev. 2.2014