Form Ad 926 - Statement Of Understanding - Parent Who Places The Child With The Prospective Adoptive Parent(S) Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATEMENT OF UNDERSTANDING
INDEPENDENT ADOPTIONS PROGRAM
Parent Who Places The Child With
The Prospective Adoptive Parent(S)
___
1. I want to place my child, ________________________________________________________________
NAME OF CHILD
permanently with ___________________________________________________________ for adoption.
NAME(S) OF THE PROSPECTIVE ADOPTIVE PARENT(S)
___
2. I have chosen the prospective adoptive parent(s) to be the parent(s) for my child based on my personal
knowledge of at least the following information about him/her/them:
PERSONAL KNOWLEDGE OF PETITIONER(S)
First Prospective Adoptive Parent:
Full Legal Name: _____________________________________________________________________
Age: ____ Religion: _____________________________ Race and Ethnicity: ____________________
Number of previous marriages: ____ Employment: __________________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
___________________________________________________________________________________
___________________________________________________________________________________
Children who do not live in the home; child support obligation for these children; and any failure to meet
child support obligations:
___________________________________________________________________________________
___________________________________________________________________________________
Any history of arrest and convictions for any crimes other than minor traffic violations:
___________________________________________________________________________________
___________________________________________________________________________________
Any removals of children from care due to child abuse or neglect:
___________________________________________________________________________________
___________________________________________________________________________________
Second Prospective Adoptive Parent:
Full Legal Name: _____________________________________________________________________
Age: ____ Religion: _____________________________ Race and Ethnicity: ____________________
Number of previous marriages: ____ Employment: __________________________________________
Health conditions restricting normal daily activities or reducing normal life expectancy:
___________________________________________________________________________________
___________________________________________________________________________________
Children who do not live in the home; child support obligation for these children; and any failure to meet
child support obligations:
___________________________________________________________________________________
___________________________________________________________________________________
Any history of arrest and convictions for any crimes other than minor traffic violations:
___________________________________________________________________________________
___________________________________________________________________________________
AD 926 (7/17) PARENT WHO PLACES THE CHILD WITH THE PROSPECTIVE ADOPTIVE PARENT(S)
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