| Father's Information |
| Have you ever failed to meet your child or spousal support obligation?* |
|
| Has any child ever been removed from your care due to abuse or neglect?* |
|
| Have you ever been deprived of parental rights or had your rights restricted?* |
|
| Have you ever been charged or accused of child abuse or neglect?* |
|
| If yes, please explain* |
| * |
| Have you been accused of, or charged with, sexual abuse against another (even if there was no conviction)? |
|
| Have you received treatment for a mental condition?* |
|
| If Yes, please explain* |
| * |
| Do you have a history of drug use? If yes, please state the drug that was used and your age at the time.* |
|
| Have you ever been treated for drug or alcohol abuse?* |
|
| If yes, please explain* |
| * |
| Do you have a history of domestic violence?* |
|
| Do you have more than 4 traffic law violations? Please list.* |
|
| Have you ever been denied a homestudy?* |
|
| If yes, please explain* |
| * |
| Have you ever been given an unfavorable homestudy?* |
|
| If yes, please explain* |
| * |
| Have you ever begun a homestudy that was never completed?* |
|
| If yes, please explain* |
| * |
| Have you ever filed bankruptcy?* |
|
| If yes, please explain* |
| * |
|
| Mother's Information |
| Have you ever failed to meet your child or spousal support obligation?* |
|
| Has any child ever been removed from your care due to abuse or neglect?* |
|
| Have you ever been deprived of parental rights or had your rights restricted?* |
|
| Have you ever been charged or accused of child abuse or neglect?* |
|
| If yes, please explain* |
| * |
| Have you been accused of, or charged with, sexual abuse against another (even if there was no conviction)?* |
|
| Have you received treatment for a mental condition?* |
|
| If Yes, please explain* |
| * |
| Do you have a history of drug use? If yes, please state the drug that was used and your age at the time.* |
|
| Have you ever been treated for drug or alcohol abuse?* |
|
| If yes, please explain* |
| * |
| Do you have a history of domestic violence?* |
|
| Do you have more than 4 traffic law violations? Please list.* |
|
| Have you ever been denied a homestudy?* |
|
| If yes, please explain* |
| * |
| Have you ever been given an unfavorable homestudy?* |
|
| If yes, please explain* |
| * |
| Have you ever begun a homestudy that was never completed?* |
|
| If yes, please explain* |
| * |
| Have you ever filed bankruptcy?* |
|
| If yes, please explain* |
| * |
|
