DPP-190

(R. 11/05)

922KAR1:010

Commonwealth of Kentucky

Department for Community Based Services

Information to be Obtained from the Proposed Adoptive Parent(s)

Note: The information you give will be held confidential. Filling out this form does not in anyway bind you or us if you should later decide not to continue your application for permission to receive a child.

Husband: Name: ______and ______

(Last) (Husband’s name) (Wife’s First and Maiden name)

______

(Husband’s Social Security number) (Wife’s Social Security number)

Address: ______

(Street #, P>O> Box or RFD)(Town)(County)(State)(Zip Code)

How long have you lived at this address? ______

If less than five years at current address, list previous address(es) ______

Telephone Number: ______

Home (Area Code) - NumberWork (Area Code) – Number

Directions for reaching the home: ______

______

THE FAMILY

Members of Family in Home / Date and Year of Birth / Sex / Religion / Race / BirthplaceCity, County, State / LastSchool Grade Completed / Adult Occupation
or Child’s School
Husband
Wife
Child
Child
Child
Others living in home

DESCRIPTION OF APPLICANTS

Members of Family in Home / Height / Weight / Color of Eyes / Color of Hair / Complexion
Husband
Wife
Child
Child
Child

KentuckyUnbridledSpirit.com An Equal Opportunity Employer M/F/D

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MARITAL HISTORY

Date of Marriage:______By whom married and where:______

Where was license bought? ______

PREVIOUS MARRIAGES

Husband / Name of Spouse / Date of Marriage / Place-County/State / Reason Terminated (Death/Divorce) / Date / Place
Wife

Attach clerk certified verifications of current marriage and prior divorces.

Children by Previous Marriages and Their Living Arrangements

Other Children Residing Away From Home

List mother, father, brothers, and sisters. If deceased, give date and cause of death. (if necessary, use separate sheet).

Family of Husband / Address / Age / Education / Occupation / No. Children
Family of Wife / Address / Age / Education / Occupation / No. Children

State reason for wanting to adopt a child:

______

State how independent arrangements to adopt the child were made:

______

List specific financial arrangements between you and the birth parent or any other agency or person:

______

Have you ever applied to take a child from this agency or any other agency or person? Yes___ No ____

If so, from whom? ______Name of Child______

Have you ever applied to receive a child from any agency or person? Yes___ No ____

If so, from whom? ______

LIST EMPLOYMENT FOR PAST FIVE YEARS AS REFERENCES

Name and address of Husband’s employer:______

Title of Position: ______Usual wage:______

Date first employed here:______Previous employment with dates:______

______

______

Give dates of Military Services:______Type of Discharge:______

Name and address of wife’s employer: ______

Title of Position: ______Usual wage:______

Date first employed here:______Previous employment with dates:______

______

______

Give dates of Military Services:______Type of Discharge:______

Annual net income:______If Farming, do you own or rent? Own Rent No. of Acres:______

Do you own your home? Yes No Present Valuation:______Present Mortgage: ______

If rented, what is monthly rent?______If buying on contract, what are contract payments?______

No. of rooms:______Will child have a room of his/her own? Yes No

Location and value of any other property owned:______

______

Other income:______Other indebtedness:______Savings:______

Total Income from All Sources:______

INSURANCE – PENSIONS OR ANNUITIES

(Include retirement, social security, etc.)

Amount / Type / Company / On Husband, Wife, Children
MEDICAL INSURANCE
Amount / Type / Company / On Husband, Wife, Children

FINANCIAL STATEMENT

Monthly Income and Other AssetsHusbandWife

Gross Salary (per month) ______

Net Salary (per month)______

Other Income (per month)______

Savings Account______

Checking Account______

Other (Investment, etc.)______

Monthly Expenditures

Mortgage Payments/Rents______

Food______

Child Support/Care______

Car payments/Related Transportation Expenses______

Insurance______

Utilities______

Installation Payments/Charge Accounts______

Recreation______

Donations______

REFERENCES

Members of family, other relatives or neighbors may be listed under personal references.

NameAddress (include zip code)

______

Husband’s Physician:______

Wife’s Physician:______

Clergyman (Optional):______

Credit 1:______Acc.#______

Credit 2:______Acc.#______

Personal 1:______

Personal 2:______

Relative 1:______

1.Have either of you ever been fined or convicted for violation of any law or are you now under charges for any violation of law? Yes___ No ____ If yes, please give details.______

2.Are either of you currently involved in a civil suit or now paying a judgment in a civil action?

Yes___ No ____ If yes, please give details.______

3.Have either of you ever had any mental, emotional, or nervous condition which required treatment?

Yes___ No ____ If yes, please give details, including physician’s name and address:______

______

4.Have either of you ever been accused of child or spouse abuse? Yes___ No ____

ATTACH DISTRICT COURT CLERK CERTIFIED RECORD SEARCH COMPLETED IN YOUR COUNTY OF RESIDENCE

NOTE: The above information is true and complete to the best of our knowledge and belief. We are aware that should investigation disclose misrepresentation or falsification, our application will be DENIED.

Signed:______

(Husband)

______

(Wife)

______

(Date)

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