ࡱ> @C=>? @ bjbj5*5* *W@W@!lllllllaaa8@ab\<h|d *o@o@o@op(CrDs$ $R-l[upp[u[u-ll@o@o}}}[u"l@ol@o}[u}}llo@opd pBՠa}u9 0<zuz,ollllzl}+t>it,}t$t+t+t+t--4d<$}d<ADOPTION APPLICATIONIMPORTANT: This form must be completed, signed by both applicants (if married) and returned to initiate adoption services.Department of Human ServicesCompletion of an adoption application is a condition of eligibility and the legal basis for starting the assessment process. Information on the form is confidential and may be used as part of the adoption process.Withheld or intentionally false information may result in denial of the adoption application. You may seek the assistance of staff or anyone of your choice in completing this form.Family NameDateArea Code/Home Telephone Number FORMTEXT       FORMTEXT       FORMTEXT      Cell Phone NumberE-Mail address FORMTEXT       FORMTEXT      Address (Number and Street) FORMTEXT      City, Village or TownshipCountyStateZip FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Applicant #1  Personal Characteristics and BackgroundFull Legal NameFormer NamesDate of BirthPlace of Birth (City, State) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      RaceU.S. Citizen  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSocial Security Number FORMTEXT      If not U.S. Citizen, type of residency: FORMTEXT       FORMTEXT      Marital StatusHave you or your spouse been ordered to pay child support?Military Service FORMCHECKBOX  S FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  W FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  NoPrevious Marriages? (#)Are there any arrearages, if so, how much?If discharged, date and type of Discharge FORMTEXT       FORMTEXT       FORMTEXT      Currently EmployedIf not employed, describe source of income FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      Applicant #2  Personal Characteristics and BackgroundFull Legal NameFormer NamesDate of BirthPlace of Birth (City, State) FORMTEXT       FORMTEXT       FORMTEXT      RaceU.S. Citizen  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSocial Security Number FORMTEXT      If not U.S. Citizen, type of residency: FORMTEXT       FORMTEXT      Marital StatusHave you or your spouse been ordered to pay child support?Military Service FORMCHECKBOX  S FORMCHECKBOX  M FORMCHECKBOX  D FORMCHECKBOX  W FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Yes  FORMCHECKBOX  NoPrevious Marriages? (#)Are there any arrearages, if so, how much?If discharged, date and type of Discharge FORMTEXT       FORMTEXT       FORMTEXT      Currently EmployedIf not employed, describe source of income FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT      HOUSEHOLD MEMBERSNameBirth DateRelationshipNameBirth DateRelationship FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      CHILDREN (MINORS OR ADULTS) LIVING OUTSIDE OF THE HOMENameBirth DateRelationshipNameBirth DateRelationship FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       1. Has any member of the household or immediate family been [list name(s)]Arrested? FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      Convicted of a crime? FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      Involved with Children s Protective Services? FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      Hospitalized and/or treated for a psychiatric disorder? FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      Hospitalized and/or treated for a chronic health problem? FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      Experienced/treated for a substance abuse problem? FORMCHECKBOX  Y       ( * , . 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FORMCHECKBOX  Yes  FORMCHECKBOX  NoName(s): FORMTEXT      2. If you are applying to adopt a specific child(ren), please name: FORMTEXT       FORMCHECKBOX  N/A3. Describe the broadest range of types of children you feel your family can parent  including age; physical, mental and emotional characteristics; children of a different background than your family; boys only, girls only or both; number of children, etc. FORMTEXT      4. Have you previously applied to be an adoptive parent? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes: Date of Application FORMTEXT      Agency Name and Address FORMTEXT      Have you previously been denied for adoption? FORMCHECKBOX  Yes  FORMCHECKBOX  NoREFERENCES  The agency has permission to contact the following references by phone, letter or in person (Must be three unrelated people)1. NameRelationshipTelephone FORMTEXT       FORMTEXT       FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      2. NameRelationshipTelephone FORMTEXT       FORMTEXT       FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      3. NameRelationshipTelephone FORMTEXT       FORMTEXT       FORMTEXT      AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      4. Applicant #1 Employer  (if applicable)Telephone FORMTEXT       FORMTEXT      Business AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      5. Applicant #2 Employer  (if applicable)Telephone FORMTEXT       FORMTEXT      Business AddressCityStateZip Code FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT       PLEASE READ THE FOLLOWING COMPLETELY:I (we) have received the following publications: Agency Adoption Program Statement (e.g. DHS-255) Adopting a Child in Michigan (DHS-823) Michigan s Adoption Subsidy Programs (DHS-538) I (we) request to be considered as an applicant to provide my (our) home for a child needing an adoptive family. I (we) have read all instructional material in this form and have completed it to the best of my (our) ability. By signing this application form, I (we) are agreeing to the following: 1. Waiving our rights to view any references submitted related to this adoption. 2. Our adoption worker will provide us with a completed family assessment, which will contain a summary of the submitted references. 3. Our adoption worker will contact our adult children and minor children residing outside of our home. 4. Complying with and meeting the agency requirements for adoption. 5. I (we) may voluntarily withdraw this application at any time and if dissatisfied with any action or failure to act affecting me (us), I (we) may request a hearing before a representative of the agency or department.Signature of ApplicantApplicant #1Date SignedSignature of ApplicantApplicant #2Date SignedAUTHORITY: P.A. 288 of 1939 COMPLETION: Mandatory. PENALTY: No adoption placementDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. DHS-3153-A (Rev. 3-09) Previous edition obsolete. MS Word  PAGE 3 See Page 3 for PA 431 information and non-discrimination statement. 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