5/15/3 Adoption Information Sheet Revised 5 15 06
ADOPTION INFORMATION SHEET
SUPERIOR COURT OF THE DISTRICT OF COLUMBIA
FAMILY COURT
DOMESTIC RELATIONS BRANCH – ADOPTION
EX PARTE IN THE MATTER OF
ADOPTION CASE NO. A-
THE PETITION OF
JUDGE RONNA LEE BECK
FOR ADOPTION OF MINOR CHILD(REN)
ADOPTION INFORMATION SHEET
1.
Petitioner’s Full Name:
2.
Petitioner's Address:
3.
Petitioner's Phone Number:
4.
Petitioner's Date of Birth:
5.
Petitioner's Social Security Number:
6.
Petitioner's Driver's License No.:
7.
Minor Child's Full Name:
8.
Minor Child's Address:
9.
Minor Child's Phone No.:
10.
Minor Child's Date of Birth:
11.
Minor Child's Place of Birth:
12.
Minor Child's Social Security Number:
13.
Neglect Case Number:
14.
Neglect Social File Number:
15.
Neglect Judge's Name:
Revised 5/15/06
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16.
Is the Mother's Affidavit of Paternity attached?
Yes or
No
17.
Has the Mother's Affidavit of Paternity been filed?
Yes or
No
18.
Please provide the case number of the case in which the affidavit was filed: ______________
19
Mother's Full Name:
20.
Mother's Last Known Address:
21.
Mother's Phone Number:
22.
Mother's Date of Birth:
23.
Mother's Social Security No.:
24.
Mother's Driver's License No.:
25.
Father's Full Name:
26.
Father's Last Known Address:
27.
Father's Phone Number:
28.
Father's Date of Birth:
29.
Father's Social Security No.:
30.
Father's Driver's License No.:
31.
Consent from Mother:
Yes or
No
32.
Consent from Father:
Yes
or
No
33.
Relinquishment from Mother:
Yes
or
No
34.
Relinquishment from Father:
Yes
or
No
35.
Termination of Mother's Parental Rights:
Yes
or
No
36.
Termination of Father's Parental Rights:
Yes
or
No
37.
Social Worker's Agency:
38.
Social Worker's Name:
39.
Next Neglect Hearing Date:
Revised 5/15/06
2
40.
Place of Hearing: Courtroom No.
Hearing Room No.
41.
Petitioner's Counsel's Name:
42.
Address:
43.
Phone Number:
44.
Fax, if any:
45.
Email, if any:
46.
Petitioner's Additional Contact Information if not Represented by Counsel:
47.
Fax, if any:
48.
Email, if any:
49.
Mother's Counsel's Name:
50.
Address:
51.
Phone Number:
52.
Father's Counsel's Name:
53.
Address:
54.
Phone Number:
55.
Guardian Ad Litem's Name:
56.
Address:
57.
Phone Number:
58.
Petitioner's Relationship to Adoptee:
59.
Child has Lived with Petitioner(s) Since:
60.
Petitioner's Marital Status:
61.
Jurisdiction in Which Petitioner(s) Reside:
62.
Competing Case: Yes
or
No
63.
If yes, Competing Case Number:
Revised 5/15/06
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