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Readoption Petitioners Fact Sheet Form. This is a Ohio form and can be use in Montgomery County (Court Of Common Pleas).
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Tags: Readoption Petitioners Fact Sheet, 19.6, Ohio County (Court Of Common Pleas), Montgomery
PROBATE COURT OF MONTGOMERY COUNTY, OHIO
ALICE O. McCOLLUM, JUDGE
READOPTION PETITIONER’S FACT SHEET
READOPTION /CHILD INFORMATION
In the Matter of the Readoption of:
Case Number:
Relationship, if any, to Petitioner:
Name to be Changed to:
Street Address:
Birth Date:
Place of Birth:
Zip:
County:
City:
State:
Name of School Child Attends: (Specify if Home Schooled)
Describe Child’s School Attendance, Behavior and Grades:
Description of Child: (Appearance, Personality, Mental Health)
Physical Health:
Date Child Entered Home of Adopting Parent(s):
Child Received from Whom:
Adjustment of Child in Home of Adopting Parent(s):
Are there other proceedings in another Court:
PARENTAL INFORMATION
PARENT ONE
PARENT TWO
Name:
Name:
Street Address:
Street Address:
City:
State:
Zip:
City:
State:
Zip:
Date of Birth (MM/DD/YYYY)
Age:
Date of Birth (MM/DD/YYYY)
Age:
Birthplace (City/State)
Nationality/Race
Birthplace (City/State)
Nationality/Race
Education: (Highest School/College)
Education: (Highest School/College)
Legal Citizen?
Yes
Marriage: (MM/DD/YYYY)
Legal Citizen?
No
Place of Marriage:
Yes
Marriage: (MM/DD/YYYY)
No
Place of Marriage:
Divorces: If Yes, Number/County/State of Divorce(s)
Divorces: If Yes, Number/County/State of Divorce(s)
Describe Health/Mental Health:
Describe Health/Mental Health:
Present Occupation/Length of Time:
Present Occupation/Length of Time:
Previouis Occupation:
Previous Occupation:
Financial Status (Income Salary, Investments, Insurance, Property):
Financial Status (Income Salary, Investments, Insurance, Property):
Description of Home: (# Bedrooms/Type of Neighborhood)
Description of Home: (# Bedrooms/Type of Neighborhood)
M.C. Form 19.6 - Readoption Petitioner’s Fact Sheet
05-19-2009
American LegalNet, Inc.
www.FormsWorkFlow.com
ADOPTING FAMILY (OTHER MEMBERS OF HOUSEHOLD)
Name:
Name:
Name:
Birth Date:
Birth Date:
Birth Date:
Highest School Grade Completed:
Highest School Grade Completed:
Highest School Grade Completed:
Physical Description: (appearance, personality,
mental health and occupation)
Physical Description: (appearance, personality,
mental health and occupation)
Physical Description: (appearance, personality,
mental health and occupation)
Note: Please use separate page for additional household members if required.
POLICE/CRIMINAL RECORD CHECK
Record Check Completed on:
(FOR ALL MEMBERS OF HOUSEHOLD OVER EIGHTEEN (18) YEARS OF AGE)
Mother
Father
Other Members of Household Over 18 Years of Age: (Please list Names/Relationship)
Please List any Police/Criminal Record Check Findings: (Name/Date/Place/Nature of Offense)
HOUSEHOLD SOCIAL/MEDICAL HISTORY
Check any of the following that are true about the child/mother/father or other household members:
Child
Mother
Father
Other: _______________________
Victim of domestic violence
Child
Mother
Father
Other: _______________________
Had contact with Child Protective Services (in/out of state)
Child
Mother
Father
Other: _______________________
Experienced a substance abuse problem
Child
Mother
Father
Other:_______________________
Experienced a mental health problem
Describe any physical and/or mental limitations you have that may affect your ability to raise this child. If None, check:
None
Describe the methods of discipline you use to control this child:
DESCRIPTION OF FAMILY LIFE
Describe the activities, interest, attitudes, and relationship of the household members:
Page 2
M.C. Form 19.6 - Readoption Petitioner’s Fact Sheet
05-19-2009
American LegalNet, Inc.
www.FormsWorkFlow.com
REFERENCES
List Name, Relationship, Occupation, Address, Telephone Number
1.
2.
3.
The undersigned acknowledges the information on this Readoption Petitioner’s Fact Sheet is to be true to the best of his/her/their knowledge.
Signed: ________________________________
Date: ___________________________________
Signed: ________________________________
Date: ______________________________
Sworn to before me and signed in my presence this ____ day of ________________________, 20____.
By__________________________________
Notary Public
My Commission Expires: _____________________________
Page 3
M.C. Form 19.6 - Readoption Petitioner’s Fact Sheet
05-19-2009
American LegalNet, Inc.
www.FormsWorkFlow.com