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