Readoption Petitioners Fact Sheet {19.6}

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: Relationship, if any, to Petitioner: Street Address: City: State: Case Number: Name to be Changed to: Birth Date: Zip: Place of Birth: County: 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): Adjustment of Child in Home of Adopting Parent(s): Child Received from Whom: Are there other proceedings in another Court: PARENTAL INFORMATION PARENT ONE Name: Street Address: City: Date of Birth (MM/DD/YYYY) Birthplace (City/State) Education: (Highest School/College) Legal Citizen? Yes Marriage: (MM/DD/YYYY) No Place of Marriage: State: Age: Nationality/Race Zip: Name: Street Address: City: Date of Birth (MM/DD/YYYY) Birthplace (City/State) Education: (Highest School/College) Legal Citizen? Yes Marriage: (MM/DD/YYYY) No Place of Marriage: State: Age: Nationality/Race Zip: PARENT TWO Divorces: If Yes, Number/County/State of Divorce(s) Describe Health/Mental Health: Present Occupation/Length of Time: Previouis Occupation: Financial Status (Income Salary, Investments, Insurance, Property): Divorces: If Yes, Number/County/State of Divorce(s) Describe Health/Mental Health: Present Occupation/Length of Time: Previous Occupation: 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: Birth Date: Highest School Grade Completed: Physical Description: (appearance, personality, mental health and occupation) Name: Birth Date: Highest School Grade Completed: Physical Description: (appearance, personality, mental health and occupation) Name: Birth Date: Highest School Grade Completed: 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 Child Child Child Mother Mother Mother Mother Father Father Father Father Other: _______________________ Other: _______________________ Other: _______________________ Other:_______________________ Victim of domestic violence Had contact with Child Protective Services (in/out of state) Experienced a substance abuse problem Experienced a mental health problem None Describe any physical and/or mental limitations you have that may affect your ability to raise this child. If None, check: 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: ________________________________ Signed: ________________________________ Date: ___________________________________ 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