OLOS™ Initial Application for aHome Study

MAN’S NAME (Last, First, Middle) Preferred NameWork Phone Number

WOMAN’S NAME (Last, First, Middle) Preferred NameWork Phone Number

STREET ADDRESS Home Phone Number

CITY STATE ZIP Cell Phone Number

Man’s E-Mail ______Driver’s License ______

Woman’s E-Mail ______Driver’s License ______

PERSONAL DATA

DOBPLACE OF BIRTH SSNCITIZENSHIPRACE AND NATIONALITY

MAN

HEIGHTWEIGHTHAIR COLOREYE COLORRELIGIONEDUCATION (Highest grade completed)

PREVIOUS STATE OF RESIDENCEHOW LONG IN ARIZONA?COUNTY OF RESIDENCEHOW LONG?

DOBPLACE OF BIRTH SSN CITIZENSHIPRACE AND NATIONALITY

WOMAN

HEIGHTWEIGHTHAIR COLOREYE COLORRELIGIONEDUCATION (Highest grade completed)

PREVIOUS STATE OF RESIDENCEHOW LONG IN ARIZONA?COUNTY OF RESIDENCEHOW LONG?

MARITAL HISTORY

DATE OF PRESENT MARRIAGEPLACE OF MARRIAGE CERTIFICATE NUMBER LEGAL CHURCH

PREVIOUS MARRIAGES (If yes, please complete the following information)

MANWOMAN

NAME OF FORMER SPOUSENAME OF FORMER SPOUSE

DATE AND PLACE OF MARRIAGEDATE AND PLACE OF MARRIAGE

HOW TERMINATED (divorce, death, annulment)HOW TERMINATED (divorce, death, annulment)

DATE, PLACE AND COURT NUMBERDATE, PLACE AND COURT NUMBER

FAMILY HISTORY

CHLDREN IN HOMEIF ADOPTED NAME OF SCHOOL GRADE

NAMEBIRTHDATESEXNAME OF AGENCY DATE ADOPTED

OTHER CHILDREN NOT LIVING AT HOME

NAME (FIRST, LAST)BIRTHDATEADDRESS

OTHERS RESIDING IN HOME Note: All over the age of 18 years must be fingerprinted.

NAME (FIRST, LAST)AGERELATIONSHIP

EXTENDED FAMILY ( If additional space is needed, please attach separate page or use back of the application)

MANNAME (FIRST, LAST)AGEADDRESS

FATHER

MOTHER

STEP-

PARENT

SIBLING

SIBLING

SIBLING

WOMANNAME (FIRST, LAST)AGEADDRESS

FATHER

MOTHER

SIBLINGS

STEP-

PARENTS

NAME (FIRST, LAST)AGEADDRESS

SIBLING NAME (FIRST, LAST)AGEADDRESS

SIBLING

SIBLING

PERSONAL INFORMATION

EMPLOYMENTMAN WOMAN

JOB

TITLE

EMPLOYER

START

DATE

HOURS

PER WEEK

If employed less than one year, list previous employer and length of service.

EDUCATIONMAN WOMAN

HIGH

SCHOOL

DATE

COMPLETED

COLLEGE/

TECHSCHOOL

DATE

COMPLETED

DEGREE OR

CERTIFICATION

MILITARY SERVICE MAN WOMAN

BRANCH

DATES OF

SERVICE

LEGAL INFORMATION

MANWOMAN

Yes YesHave you ever been arrested? If so, please explain in written detail with date and location of arrest:

No No

Yes NoHave you ever been investigated by Child Protective Services? If so, please explain and provide state and date:

Have you ever been a party to:

Allegations of abuse, neglect or abandonment of a child?

A dependency action for a child?

A termination of parent/child relationship?

If so, please explain:

______

Have you ever been ordered to pay child support or involved in a child custody action? If so, please explain:

______

Have you ever had surgery? If so, please explain:

______

Are you presently under the care of a physician for any medical condition? If so, please explain:

MAN/ WOMAN

Are you presently taking any medication? If so, please explain:

Have you ever received psychiatric treatment? If so, please explain:

Have you ever received alcohol or substance abuse treatment? If so, please explain:

Have you ever received marital, family, or individual counseling?

FINANCIAL INFORMATION

Have you ever filed for bankruptcy either individually or as a couple? Yes No (If yes, please complete the following)

DATE FILEDDATE DISCHARGEDPLACE FILED COURTNUMBER

______

CIRCUMSTANCES OF BANKRUPTCY (Copy of document must be included for review by the court)

Income may be verified with the cover sheet of your Income Tax Return/ Pay Stubs and Bank Statements

MONTHLY INCOMEGROSSNET

HUSBAND$$

WIFE$$

OTHER INCOME (List source)

TOTAL INCOME:$

MONTHLY EXPENSES

MORTGAGE PAYMENT/RENT$ HOME OWN ______RENT ______

UTILITIES$

FOOD$

CLOTHING$ SQUARE FEET______

MEDICAL/DENTAL$

GASOLINE$

AUTO LICENSING$

AUTO MAINTENANCE$

PET CARE$

RECREATION/ENTERTAINMENT$

CHARITABLE CONTRIBUTIONS$

CHILD SUPPORT$

CHILD CARE/TUITION$

ADULT EDUCATION$

LOANS (List type and lender)OUTSTANDING BALANCE

$$

$$

INSURANCE (List type and company)AMOUNT OF COVERATE

$$

CREDIT CARDS$$

$$

$$

TOTAL PAYMENTS$

CURRENT

ASSETS VALUEEQUITYPAID FOR?

HOME$$ $

OTHER REAL ESTATE

$$ $

$$ $

VEHICLES (Make, model, year)

$

$

$

BOATS/RVs (Make, model, year) NAME OF ANIMAL______TAG # ______

$

PERSONAL PROPERTY$ NAME OF ANIMAL______TAG # ______

ANIMALS VALUE $ NAME OF ANIMAL______TAG # ______

SWIMMING POOL ______FENCE ______WEAPONS ______

ACCOUNTS/INVESTMENTSFINANCIAL INSTITUTIONAMOUNT

CHECKING ACCOUNTS$

$

$

SAVINGS ACCOUNTS$

$

$

STOCKS/BONDS$

RETIREMENT ACCOUNTS$

$

INVESTMENT ACCOUNTS$

$

REFERENCES

Please list three non-relative and two relative references who have known you well over a period of years.

1.NameTelephone:

Address______

CityState/Zip

2.NameTelephone:

Address

CityState/Zip

3.Name Telephone:

Address

City State/Zip

4.Name Telephone:

Address

City State/Zip

5.Name Telephone:

Address

City State/Zip

I understand that all information will be verified as part of the agency investigation in the preparation of the report for the court. To the best of our/my knowledge, the information provided in this application is accurate.

Woman’s SignatureDate

Man’s SignatureDate

Please return the completed application and the following documents to the address listed below:

  • Copies of family members birth certificates, medical examinations forms and marriage license
  • $100.00 check or Money Order payable to OLOS (non refundable application fee)
  • Balance of the fee due at the time of the home visit, total dueten days prior to the final hearing date.

OLOSAdoption and Child Welfare Agency

Polly Thomas, ACSW, LCSW

5331 W. Morgan Place

Chandler, Arizona85226

Telephone: 480-730-5111

Fax: 480-491-2589 PT:5/07

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OLOS…………………………Making a difference in the life of every child.