Form Dshs 10-114 - Adoption Data Card - Washington Department Of Social And Health Services
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4ADOPTION DATA CARD, DSHS 10-114(X)
INSTRUCTIONS
Why information is needed and legal authority:
According to RCW 26.33.300, an Adoption Data Card must be completed and filed with the clerk of the court on behalf of the petitioner
for each individual adopted. Under the federal requirements of the Adoption and Foster Care Analysis and Reporting System
(AFCARS), the State must report on all adoptions which occurred since October 1, 1994, and in whose adoption Title IV-B/IV-C agency
has had any involvement. AFCARS reports on all other adoptions are encouraged but are voluntary. Reports on the following
adoptions are mandated:
a. All children adopted who had been in foster care under the responsibility and care of the Department of Social and Health
Services (DSHS) and who were subsequently adopted whether special needs or not and whether subsidies are provided or
not.
b. All special needs children who were adopted in the State of Washington, whether or not they were in the public foster care
system prior to their adoption and for whom non-recurring expenses were reimbursed.
c. All children adopted for whom an adoption assistance payment or service is being provided based on arrangements made
by or through DSHS.
SECTION I. CHILD INFORMATION
Item 1 – 5
Self-explanatory.
Item 6
In general, a person’s race is determined by how others define them or by how they define themselves. In the case of
young children, parents determine the race of the child.
White:
a person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
Black or African American:
a person whose ancestry is any of the black racial groups of Africa.
American Indian/Alaskan Native:
a person having origins in any of the original peoples of North or South America
(including Central American) and who maintains tribal affiliation or community
attachment.
Asian:
a person having origins in any of the original peoples of the Far East, Southeast Asia,
or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Native Hawaiian or other Pacific Islander:
a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
Item 7
Self- explanatory
Item 8
Use the State definition of special needs as it pertains to a child eligible for an adoption subsidy.
Item 9
Check the factor or condition for categorization as special needs. Check all that apply.
Item 10
Check the factor or condition as defined by the State and clinically diagnosed by a qualified professional. Check all that
apply.
Item 11
Date child was placed with adoptive family, either on foster or adoptive basis.
Item 12
Date child was placed in foster care following most recent removal from birth family.
SECTIONS II. BIRTH PARENT INFORMATION
Item 1
Enter the year of birth for each birth parent. If the exact year of birth is unknown, enter an estimated year of birth.
Item 2
Race: see instructions and definitions under SECTION I., Item 6.
Item 3
Self-explanatory.
Item 4
Self-explanatory.
Item 5
Enter the month, date, and year of termination of parental rights (TPR), voluntary relinquishment or death of birth
mother or father.
SECTIONS III. PETITIONERS INFORMATION
Item 1
Enter the year of birth for each petitioner. If the exact year of birth is unknown, enter an estimated year of birth.
Item 2
Self-explanatory.
Item 3
Race: see instructions and definitions under SECTION I., Item 6.
Item 4
Self-explanatory.
Item 5
Self-explanatory.
ADOPTION DATA CARD
DSHS 10-114 (REV. 06/2001)
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