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Sample Wording #2 - Supervised Provider:

“Prepared in foreign country by Anne Marie Davis, LCSW, license # 17895, expires 12/31/2008, who is authorized

by the State of X to research and prepare home studies. Anne Marie Davis is a supervised provider for American

Adoption Services, Inc., based on an agreement executed on July 26, 2008, signed by American Adoption Services,

Inc. In accordance with 22 CFR Part 96, American Adoption Services, Inc. (State X license # 99451, expires

November 10, 2009) is an accredited agency on file with the U.S. Department of State as having the authority to

provide adoption services in a Convention adoption. American Adoption Services, Inc., supervised, reviewed, and

approved the home study for Mr. and Mrs. Smith conducted by Anne Marie Davis and has met the conditions set forth

in 22 CFR 96.47(c).”

Sample Wording #3 - Accredited Agency

“Prepared by Madeline Duncan, LCSW, license 17895, expires 12/31/2008, who is authorized by the State of X under

LAW 12345 (e) to prepare home studies and is employed by American Adoption Services, Inc. In accordance with 22

CFR Part 96, American Adoption Services, Inc., is an accredited agency on file with the U.S. Department of State as

having the authority to conduct Hague Convention home studies.”

Sample Wording #4 - Public Domestic Authority

“Prepared by Josephine Smith, a case worker under the authority of the Department of Social Services Child Welfare

Division of the State of X.”

16. The home study must contain the home study preparer’s signature. In the case of a home study that is reviewed

and approved by an accredited or temporarily accredited agency, the home study should include the signature of the

preparer AND the designated representative of the accredited agency assuming responsibility for the home study. The

home study preparer’s signature must include a declaration, under penalty of perjury under U.S. law, that:

A. The signer personally, and with the professional diligence reasonably necessary to protect the best interests of any

child whom the applicant might adopt, either actually conducted or supervised the home study, including personal

interviews, home visits, and all other aspects of the investigation needed to prepare the home study;

NOTE: If the signer did not personally conduct the home study, the person who actually did so must be

identified.

B. The factual statements in the home study are true and correct to the best of the signer’s knowledge, information,

and belief; and

C. The home study preparer has advised the applicant of the duty of candor, specifically including the ongoing duty

concerning disclosure of new events or information warranting submission of an updated or amended home study.

Sample Wording - Home study was conducted by signer

“I, Anne Marie Davis, hereby certify under penalty of perjury that I personally, and with professional diligence

reasonably necessary to protect the best interests of any child whom the applicant might adopt, conducted this home

study, including personal interviews, the home visit, and all other aspects of the investigation needed to prepare the

home study. The factual statements in the home study are true and correct to the best of my knowledge, information,

and belief. I have advised the applicants of the duty of candor, specifically noting the ongoing duty of disclosure of

new events or information, that may require an updated or amended home study. This home study was performed in

accordance with 8 CFR 204.311 and is a true and accurate copy of the home study provided to the PAP or USCIS.”

Form M-738 Instructions 07/27/09 N

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Instructions For Form M-738 - Hague Home Study Tip Sheet For Adoption Service Providers And Prospective Adoptive Parents Page 7