Form Dshs 10-114 - Adoption Data Card - Washington Department Of Social And Health Services Page 4
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4III. PETITIONER(S) INFORMATION
PETITIONER 1 INFORMATION
PETITIONER 2 INFORMATION
1. YEAR OF BIRTH:
2. SEX:
1. YEAR OF BIRTH:
2. SEX:
Male
Female
Male
Female
3. RACE (Check all that apply):
3. RACE (Check all that apply):
White
White
Black or African American
Black or African American
American Indian/Alaska Native
American Indian/Alaska Native
Asian
Asian
Native Hawaiian or other Pacific Islander
Native Hawaiian or other Pacific Islander
4. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM
4. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM
TO BE SPANISH/HISPANIC/LATINO?
TO BE SPANISH/HISPANIC/LATINO?
No, not Spanish/Hispanic/Latino
No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Cuban
Yes, Mexican/Mexican American/Chicano
Yes, Mexican/Mexican American/Chicano
Yes, Puerto Rican
Yes, Puerto Rican
Other Spanish/Hispanic/Latino
Other Spanish/Hispanic/Latino
5. MARITAL STATUS AT TIME OF BIRTH:
5. MARITAL STATUS AT TIME OF BIRTH:
Married Couple
Single Man
Married Couple
Single Man
Unmarried Couple
Single Woman
Unmarried Couple
Single Woman
IV. ADOPTION PLACEMENT INFORMATION
1. LOCATION OF AGENCY/
2. AGENCY/INDIVIDUAL WHICH PLACED CHILD FOR ADOPTION:
3. CHILD'S RELATIONSHIP TO
ADOPTIVE PARENTS:
INDIVIDUAL WITH CUSTODY
Public agency
Birth Parent
WHEN PETITION FILED:
Stepparent
Private agency
Independent person
Within state
Other relative of child
Name:
Foster Parent of child
Another state
Public DSHS and private agency
Tribal agency
Non-related
Another country
PA Name:
4. ADOPTION SUPPORT INFORMATION:
YES
NO
a. Is there a signed adoption support agreement, if no, skip to number 5. . . . . . . . . . . . . . . . . . . . . . .
b. Is monthly maintenance (state or federal) being received?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. Enter the amount of monthly maintenance: $
d. Is Title XIX/XX medical being received? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. Is the child I-VE eligible?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. PLACEMENT INFORMATION (TO BE COMPLETED IF DSHS ADOPTION):
YES
NO
Was child in state funded foster care prior to adoptive placement?. . . . . . . . . . . . . . . . . . . . .
Was child placed with own (birth) siblings in this adoptive home? . . . . . . . . . . . . . . . . . . . . . .
Was child in prior adoptive or pre-adoptive placement?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
V. AGENCY OR INDIVIDUAL COMPLETING POST PLACEMENT REPORT (CHECK ONE)
Department of Social and Health Services (DSHS)
Court employee
Report not
Washington Private Child Placement Agency
Other court appointed individual
completed
IV. INDIVIDUAL COMPLETING FORM
:
NAME:
TELEPHONE NUMBER
ADDRESS:
CITY:
STATE:
ZIP CODE:
THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE
SIGNATURE:
VII. COURT INFORMATION (TO BE COMPLETED BY THE COURT)
PETITION NUMBER:
DATE PETITION FILED:
FINAL DECREE GRANTED:
COUNTY:
COUNTY CODE:
COURT CLERK OR DESIGNEE’S SIGNATURE:
TO ORDER THIS FORM:
Mail your request to DSHS Forms and Publications Warehouse, MS 45816, PO Box 45816, Olympia, WA 98504-5816, Fax to 360-664-0597, or email to
DSHS
Forms&Pubfororders@dshs.wa.gov
. If you have Outlook or Exchange e-mail systems then you can use the DSHS 17-011 Word 7 version on the
intranet. It can be automatically sent by using the send buttons on the bottom of the form (does not work with GroupWise).
ADOPTION DATA CARD
DSHS 10-114 (REV. 00/2001)
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