State of Minnesota County Judicial District: Court File Number: Case Type: District Court Adoption ­ Stepparent In Re the Petition of: , Petitioner/Parent And , Petitioner/Stepparent To Adopt: , (child's current name) , (child's current name) . (child's current name) Stepparent Adoption Affidavit Checklist if Post-Placement Assessment Waived State of Minnesota County of Petitioners, 1. ) ) SS ) [parent's name] [hereinafter "parent"] and [stepparent's name] [hereinafter "stepparent"], state as follows: This Stepparent Adoption Affidavit Checklist is being filed in lieu of the Post-Placement Assessment Report, which the Petitioners have requested that the Court waive. 2. Petitioners were married on City of [county], State of Question [date of marriage] in the [city], County of [state]. Parent Stepparent Response Response Yes No Yes No Yes No Yes No Yes Yes No No No Yes Yes Yes No No No No. 1. 2. 3. 4. 5. Is this adoption being contested by the other birth parent? Is/are the child(ren) you are seeking to adopt over 14 years of age? If "yes," the child(ren) must consent to the adoption. Are there any minor brothers and/or sisters of the child being adopted who are not included in the adoption request? Have you ever been divorced or had a marriage dissolved? Do you have any child from any prior marriages or relationships Yes ADO210 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com No. Question living in the home with you? Are you under a court order for payment of child support in Minnesota or any other state? Has any action for mental commitment or involuntary hospitalization been taken against you in any state? Have you or any member of your family participated in family support services (i.e., family counseling, individual therapy, parenting classes, etc.) either voluntarily or involuntarily? Have you been involved in any involuntary child welfare intervention? Have you ever been the subject of a report for child dependency/neglect, child abuse, sexual abuse or domestic violence in Minnesota or any other state? Have you ever been arrested or convicted of a felony or gross misdemeanor (including DWI, sex offense or assault charges)? Has involvement with drugs or alcohol brought you into contact with any of the following systems: courts, counseling, treatment, hospitalization, law enforcement or social services? Parent Stepparent Response Response Yes Yes Yes No No No Yes Yes Yes No No No 6. 7. 8. 9. 10. Yes Yes No No Yes Yes No No 11. 12. Yes Yes No No Yes Yes No No 13. If any of the above questions are answered "Yes," Petitioners have attached to this Affidavit a separate sheet of paper, signed by both Petitioners in the presence of a notary public, providing a detailed explanation about such response. 14. Please list where you have lived during the last five years, including street address, city, state, zip code, county, and approximate dates): Address City State Dates Address City State Dates ADO210 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Address City State Dates Address City State Dates Further affiants sayeth not except that this affidavit is made in good faith in support of their request to waive the post-placement assessment. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: Petitioner/Parent Dated: Petitioner/Stepparent VERIFICATION AND ACKNOWLEDGEMENT The above-named Petitioner/Parent, [parent's name], states that Petitioner has read the foregoing Stepparent Affidavit Checklist subscribed by him/her, that Petitioner knows the contents thereof, and that the same is true to Petitioner's best information and belief. [parent's name] Petitioner / Parent [signature] The above-named Petitioner/Stepparent, [stepparent's name], states that Petitioner has read the foregoing Stepparent Affidavit Checklist subscribed by him/her, that Petitioner knows the contents thereof, and that the same is true to Petitioner's best information and belief. [stepparent's name] Petitioner / Stepparent [signature] ADO210 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com