ADOPTION FORMS FOR WEBSITE

ADOPTION FORMS FOR MARRIED COUPLES Adoption form for married couples Corporal Punishment Statement for married couples Confidential Financial Statement for married couples Financial Fee Agreement for married couples Questionnaire for married couples

JEWISH SOCIAL SERVICE AGENCY/ADOPTION OPTIONS

APPLICATION – MARRIED COUPLES DATE OF APPLICATION: HUSBAND'S FULL NAME: Social Security Number: DATE OF BIRTH:__________________________________ PASSPORT NO: NEEDED IF THIS IS AN INTERNATIONAL ADOPTION. WIFE’S FULL NAME include maiden name: Social Security Number: ______________________________________ DATE OF BIRTH:______________________________________ PASSPORT NO: NEEDED IF THIS IS AN INTERNATIONAL ADOPTION Home Address: ____________________________________________________ COUNTY:______________________________________ PHONES: Home: Business Husband _________________ Cell Husband:________________________________________ EMAIL Husband________________________________________ Business Wife Cell wife________________________

FAX #: Email wife:________________________________ Is this a Domestic or International adoption? FROM WHICH COUNTRY? NAME OF PLACING AGENCY: ADDRESS PHONE # EMAIL CONTACT PERSON: ____________________________ FAX: __________________

MARRIAGE Date of Marriage: Place: (city, county, state) Has either had a previous marriage? Husband Wife If so, give full name of previous spouse, date and place of marriage, date and place of termination, how terminated: Please provide a copy of your divorce decree for the record.

DESCRIPTION OF APPLICANTS

Husband Wife Birth Date: ______________________ ______________________ Birth Place: _____________________ ______________________ (City, county, state) (City, county, state) Are you a ______________________ _______________________ U.S. citizen? (If naturalized, give place, date, certificate #) Religion: _______________________ _______________________ Race: _______________________ _______________________ Nationality/ _______________________ _______________________ Descent: Height: _______________________ _______________________ Weight: _______________________ _______________________ Hair: _______________________ _______________________ Eyes: _______________________ _______________________ Complexion: ___________________ _____________________ HEALTH List names and addresses of attending physicians: Husband Wife Family Physician: _______________________ _______________________ Address: _______________________ _______________________ List significant medical and/or psychiatric problems for which you have received treatment. List names and addresses of attending physicians:

Husband:____________________________________________________________________ Wife:________________________________________________________________________ Physician treating infertility:________________________________________________

EDUCATION Husband Wife List schools, dates attended, degrees __________________________ ________________________ beginning with high school: __________________________ ________________________ __________________________ ________________________ __________________________ ________________________ EMPLOYMENT Name and address of current employer: ____________________________ ________________________ GIVE COMPLETE ADDRESS. ____________________________ ________________________ Title/Position: ____________________________ ________________________ Date job started: ____________________________ ________________________ Annual salary: ____________________________ ________________________ Work history last ten years. Begin with most recent employment: (Use additional sheet if necessary or SUBMIT RESUME.) Name/address of Employer: _______________________ ________________________ Type of work: _______________________ ________________________ Dates of employment:_________________________ ________________________ Name/address of employer: ________________________ ________________________ Type of work: ___________________________ ________________________

Dates of employment:___________________________ ________________________ Name/address of employer: ___________________________ ________________________ Type of work: ___________________________ ________________________ Dates of employment:___________________________ ________________________ CHILDREN Please list all children including those from this or another marriage: Birth If Deceased. Name Sex Date Adopted Custody Date and Cause ______________________________________________________________________________ ______________________________________________________________________________ HOME Describe your home:________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Do you: own ( ) rent ( ) Water/Sewer system: public( ) private ( ) If private, describe:_________________________________________________________ INSURANCE Husband Wife Company/amount of life insurance: __________________________ ________________________ __________________________ ________________________

__________________________ ________________________ Beneficiary: __________________________ ________________________ Health insurance: __________________________ ________________________ __________________________ ________________________ Will an adopted __________________________ ________________________ child be covered at time of placement?

FAMILY Husband's Family Name of father: Age/Year of birth____________________ Location: _____________________________ Employment/Retired:_______________________________________________________ Education: include degree and major: ____________________________________ Name of mother: ___________________Age/Year of birth______________________ Location: _____________________________ Employment/retired:_______________________________________________________ Education: including degree and major: ___________________________________ Sisters and Brothers Name: ________________________________ Age/Year of birth:__________________ Location: _____________________________Married/divorced/single___________ Level of education and degree: _____________________________________________ # of Children and ages:______________________________________________________ Type of employment: ______________________________________________________

Sisters and Brothers Name: __________________________________ Age/Year of birth:________________ Location: __________________________Married/divorced/single_______________ Level of education and degree: ____________________________________________ # of Children and ages: ___________________________________________________ Type of employment: ______________________________________________________ Sisters and Brothers Name: __________________________________ Age/Year of birth:_______________ Location: ___________________________ Married/divorced/single____________ Level of education and degree: ___________________________________________ # of Children and ages: ___________________________________________________ Type of employment: _____________________________________________________ Sisters and Brothers Name: _____________________________ Age/Year of birth: ________________ Location: _________________________ Married/divorced/single _____________ Level of education and degree: ___________________________________________ # of Children and ages: ___________________________________________________ Type of employment: ______________________________________________________ If additional space is needed, please attach a sheet of paper to the application. ================================================================ Wife's Family Name of father: Age/Year of birth_____________ Location: ___________________________

Employment/Retired:_______________________________________________________ Education: include degree and major: _____________________________________ Name of mother: Age/Year of birth_____________ Location: ___________________________ Employment/Retired:_______________________________________________________ Education: include degree and major: _____________________________________ Sisters and Brothers Name: __________________________________ Age/Date of birth:_____________ Location: ___________________________Married/divorced/single_____________ Level of education and degree: __________________________________________ # of Children and ages____________________________________________________ Type of employment: _____________________________________________________ Sisters and Brothers Name: __________________________________ Age/Date of birth: _____________ Location: __________________________Married/divorced/single______________ Level of education and degree: ____________________________________________ # of Children and ages______________________________________________________ Type of employment:_______________________________________________________ Sisters and Brothers Name: __________________________________ Age/Date of birth: _____________ Location: __________________________Married/divorced/single______________ Level of education and degree: ____________________________________________

# of Children and ages______________________________________________________ Type of employment:_______________________________________________________ Sisters and Brothers Name: __________________________________Age/Year of birth: ______________ Location: _____________________________ Married/divorced/single__________ Level of education and degree: ___________________________________________ # of Children and ages:____________________________________________________ Type of employment: ____________________________________________________

REFERENCES List four personal references. Do not include physician, Rabbi, or relatives: (Please print clearly, supply full mailing address and zip code, PHONE AND EMAIL ADDRESS. Please select at least one local reference who would be available to meet in-person with the caseworker at either JSSA=s Maryland or Virginia office. Name Address and zip code 1. ___________________________________________________________________________ PHONE # & EMAIL ADDRESS: _____________________________________________ 2.____________________________________________________________________________ PHONE # & EMAIL ADDRESS: _____________________________________________ 3.____________________________________________________________________________ PHONE # & EMAIL ADDRESS: ___________________________________________ 4.____________________________________________________________________________

PHONE # & EMAIL ADDRESS: ___________________________________________ Have either of you ever been arrested? If so, explain: ______________________________________________________________________________ ______________________________________________________________________________ Have you ever applied elsewhere for a child? ________ When? _____________ From whom? ________________________________Status of application?________

CHILD CARE For how long do either of you plan to stay home with the child? ______________________________________________________________________________ ______________________________________________________________________________ GUARDIANSHIP: Please name a guardian for your child. This is required in Maryland and Virginia. Give name, address, phone, age and relationship – form in the packet. THANK YOU FOR TAKING THE TIME TO COMPLETE THIS APPLICATION.

SIGNATURE PAGE We certify that all answers are true. Husband's Signature: _______________________________________________ NAME PRINTED: __________________________________________ Date Application signed: __________________________________________ Wife's Signature: ________________________________________________ NAME PRINTED: ___________________________________________ DATE Application signed: ___________________________________________ DIRECTIONS TO YOUR HOME:___________________________________________ ___________________________________________________________________________

JEWISH SOCIAL SERVICE AGENCY ADOPTION OPTIONS

CORPORAL PUNISHMENT STATEMENT MARRIED APPLICANTS

MARYLAND AND VIRGINIA RESIDENTS The Jewish Social Service Agency believes that children develop and mature best in an atmosphere of love and mutual respect. Parents fulfill their roles of nurturer and teacher best through methods that increase the child's self-esteem, sense of responsibility and independence. These methods vary with the child's age and maturity but may include open communication of values and expectation, positive reinforcement, time-out, and restriction of privileges. In compliance with federal and state guidelines, this agency firmly believes that the use of corporal punishment is neither an acceptable nor a useful tool for teaching or correcting a child of any age. There is significant potential for physical or emotional harm to a child through this practice. Therefore, use of corporal punishment is strictly prohibited by agency staff, foster parents, or adoptive parents. It is also prohibited for a staff member or parent to give permission for others to use corporal punishment. I understand that "corporal punishment" means the inflicting of pain or discomfort. Prohibited actions include but are not limited to hitting with any part of the body or with an implement, pinching, pulling, shaking, binding a child, forcing him to assume an uncomfortable position, or locking him in a room or closet. SHAKEN BABY SYNDROME: During the home study process and prior to approving any family for placement of a child, the child-placing agency shall inform the prospective foster or adoptive parents information about SHAKEN BABY SYNDROME, its effects, and that resources for help and support for caretakers may be found on the Virginia Department of Social Services public website at: http://www.dss.virginia.gov/family/cps/shakenbaby.cgi I have read this policy statement and promise to abide by these guidelines to the best of my ability for any child placed by the agency. ___________________________________ DATE:__________________________ Adoptive Father ___________________________________ DATE:__________________________ Adoptive Mother NAMES PRINTED:______________________________

ADOPTION OPTIONS-JEWISH SOCIAL SERVICE AGENCY Confidential Financial Statement

MARRIED APPLICANTS APPLICANTS NAME_________________________(printed) DATE:_______________ INCOME HUSBAND WIFE Gross Taxable Income from: Business income $ $__________ Salary income $ $__________ Child Support Payments received $________________ $__________ Other (e.g. dividends/interest) $ $__________ (Specify) $ $__________ $ $__________ TOTAL INCOME: $ $__________ ASSETS Cash: Savings Accounts $ Checking Accounts $ Investments: Stocks $ Bonds $ Real Estate : Home $ Other Properties $ Accounts & Notes Receivable: $ Cash Value-Life Insurance: $ Automobile(s): $____________ Personal Property: (furniture, clothing, collections, others: $ ___________ Estimated value of business, if self-employed: $ Other (Specify) $ $ $

Confidential Financial Statement MARRIED APPLICANTS

APPLICANTS NAME______________________(PRINTED) DATE:__________________ MONTHLY EXPENSES AND LIABILITIES: MONTHLY PAYMENT OUTSTANDING BALANCE Credit cards $ $_________________ Notes payable $________________ $_________________ MORTGAGES: Primary Residence $________________ $__________________ Rental Property $________________ $__________________ Rental Income $________________ Automobile Loans $________________ $___________________ College Loans $________________ $___________________ Utilities $________________ $___________________ NET WORTH: $_____________________ ADDITIONAL INFORMATION Health Insurance Carrier Type of Plan: ______________ Life Insurance Co: _________________________________ AMT. OF LIFE INSURANCE: HUSBAND:$___________BENEFICIARY______________ AMT OF LIFE INSURANCE: WIFE: $___________ BENEFICIARY__________________ Signature:___________________________ DATE :___________________ Signature:________________________________ DATE ___________________

A BREAKDOWN OF MONTHLY INCOME AND EXPENSES

APPLICANTS NAME____________________________ DATE:__________________ Please print name NET MONTHLY INCOME: SALARIES:____________________________________ RENTAL INCOME:___________________________________ INTEREST/DIVIDENDS INCOME:____________________ CHILD SUPPORT INCOME:__________________________ ALIMONY INCOME:__________________________________ CONSULTING INCOME:______________________________ Total Monthly Income:______________ MONTHLY EXPENSES: HOME MORTGAGE:________________________ OTHER MORTGAGES:______________________ ALL UTILITIES:____________________________ AUTOMOBILE(s) UPKEEP:___________________ CAR LOAN: outstanding amount:______________ Monthly payment:_________ GROCERIES:_______________________________ CREDIT CARDS: outstanding amount:___________ Monthly payment________ INSURANCE PREMIUMS:____________________ ENTERTAINMENT:__________________________ CHARITIES:________________________________ OTHER EXPENSES:________________________ Total Monthly Expenses:___________________

JEWISH SOCIAL SERVICE AGENCY

ADOPTION OPTIONS Financial Fee Agreement

MARRIED COUPLES

We______________ and _______________ understand that the fee for a completed DOMESTIC OR “NON-HAGUE COUNTRY” adoption home study is $1,700, plus a $100 non-refundable application fee, payable in advance. We understand that the fee for a “HAGUE COUNTRY” HOME STUDY is $1,950 plus a $100 non-refundable application fee payable in advance. We understand that if we request an expedited (RUSH) home study, the fee will be $1,900, plus a $100 non-refundable application fee, payable in advance. We understand there will be a charge of $60 per hour, with a minimum charge of $30, for preparation of forms required for dossiers or forms, in general, required by my placing agency. If we withdraw from the home study process, prior to the home study being completed, we understand that the fee for services rendered will be charged at $130.00 per hour. This fee will include service time for interviews, travel, documentation and related services. (If we withdraw, or the agency determines it cannot complete the home study, we understand we will receive a refund if there is a difference between the total hourly bill and the initial home study fee paid at the time of application.) We understand that if we request an update for a home study, prepared by Adoption Options, the fee for an update will be $500. We understand that if we request an update for a home study prepared by another agency, the fee is $500 plus an additional fee of $75 to review the original home study. We understand that the Agency’s fee for post-placement supervision is $350 per visit, for one child, and $475 per visit, for two children. This fee will include a written supervisory report, a copy of which will be available to me. If a court report is required, there will be an additional charge of $350 per report, for one child, and $475 for two children. We further understand that if we are doing a Virginia Parental Placement Adoption, we will be charged at $100.00 an hour for all services rendered other than the home study, post-placement supervision, and updates. We acknowledge that we will be charged for the social worker’s mandatory joint

counseling session with the birth(s) and prospective adoptive parents, phone calls, consultation with prospective adoptive parents, counseling with birthparent(s), preparation of the court reports and travel time. We understand that aggregate charges for a completed Virginia Parental Placement generally totals approximately $3,000. Adoption Options/JSSA reserves the right to request fees in advance for Virginia Parental Placement service. In all cases where pre-placement counseling is provided to prospective adoptive parents, a fee of $130 per hour (pro-rated) will be charged. These services may include the review of birthparent medical/social background information; interviewing the birthparents’ and discussing specific placement referrals with prospective adoptive families. We understand that an additional fee for travel will be charged to clients who live beyond 25 miles from the office. This fee will be $50.00 per hour, (pro-rated) and charged after the worker has traveled the initial 25 miles. We understand and agree that should fees for post-placement,

updates, or court reports increase either before or during the time these services are being provided, we will be responsible for reimbursing Adoption Options/JSSA at the higher fee. If we have prepaid for these services, we understand and agree that we will be responsible for paying the difference between what had been paid and the new fee.

We have read and understand all of the terms of this Financial Fee Agreement. Adoption Options/JSSA provided me with an opportunity to ask questions about the terms of this Financial Fee Agreement and answered all of our questions to our satisfaction. We freely agree to be bound by the terms of this Financial Fee Agreement and to pay promptly all applicable costs and fees. Applicant: Please print name Applicant:_____________________________ _______________________ Please print name Date Signed: ________________________ Financial fee agreement couples

ADOPTIVE FAMILY QUESTIONNAIRE

This questionnaire is designed to start you thinking about adoption issues. Please express your personal feelings and views so we may get to know you better. As part of the home study process, we will be discussing many of these questions and it is helpful if you have already begun to consider your views and feelings. Be assured that there are no right or wrong answers. Please make sure that both you and your spouse answer the questions separately. Use additional paper if necessary. Wife: Name __________________________ Date: _____________________ Husband: Name _________________________ Date:_____________________ 1) Describe your basic personality. W - H - 2. Describe your spouse's basic personality. W - H - 3. What are the strengths of your relationship and what are the areas you

with to improve? W- H- 4. Have you ever considered separation or divorce and if so, what were the

circumstances? How did you resolve your differences? W - H -

5. How do you feel about using counseling? W - H - 6. What are the personality traits that you most value about your spouse? W - H ? 7. In what ways are you and your spouse similar and in what way are you

different? W - H - 8. What activities do you enjoy doing as a couple? W - H - 9. What activities do you participate in individually? W - H - 10.) List three personal goals. W - 1. 2. 3. H - 1. 2. 3.

11. List three goals you and your spouse share. 1. 2. 3. 12. What values are most important to you? W - H - 13. What has been your greatest personal achievement? W - H - 14. What has been your family's greatest accomplishment? W - H - 15. What are your thoughts on child rearing and discipline. W - H - 16. How were you disciplined as a child and what form of discipline do you

plan to use with your child? W - H - 17. Why is adoption a positive alternative for you? W - H -

18. Do you have specific concerns about adopting? W - H - 19. What racial or cultural backgrounds are you willing to accept in a child? W H W H black twins Bi-racial mother unwed White product of rape Asian product of incest

20. What strengths and background experiences do you have that will aid you to parenting a child of this background?

W - H - 21. Describe a stressful time in your life and what coping mechanisms do

you use to help you deal with stress? W - H - 22. What expectations would you have for your child? W - H - 23. What behaviors would you find difficult to deal with in your child? W - H -

24. What goals would you like to see your child achieve? W - H - 25. What values do you feel would be most important to teach your child? W - H - 26. What do you do when someone you love chooses to be or to do something

that is in conflict with your values? W - H - 27. Would you tell your child of his/her adoption? If so, when and how do you

think you should do it? W - H - 28. How do you feel about an adoptive child's desire to gain information about

his/her biological parents? W - H - 29) Define the following: love - parent - sexuality - mother - father - child -

trust - self-image - support - expectations - Signed:_____________________________ DATE_____________________ Signed:_____________________________ DATE_____________________