Preplacement Application and Affidavit fillable form

Preplacement application of Case number Applicant 1 first middle last Applicant 1 birth date Applicant 1 birthplace Applicant 1 citizenship Applicant 1 hair color Applicant 1 eyes Applicant 1 height Applicant 1 weight Applicant 1 education high school and other Applicant 1 education high school and other line 2 Applicant 1 occupation Applicant 1 time employed Applicant 1 salary Applicant 1 employer name address and phone line 1 Applicant 1 employer name address and phone line 2 Applicant 1 previous marriages spouse name marriage place and date how when and where terminated line 1 Applicant 1 previous marriages spouse name marriage place and date how when and where terminated line 2 Applicant 2 first middle last Applicant 2 birth date Applicant 2 birthplace Applicant 2 citizenship Applicant 2 hair color Applicant 2 eyes Applicant 2 height Applicant 2 weight Applicant 2 education high school and other line 1 Applicant 2 education high school and other line 2 Applicant 2 occupation Applicant 2 time employed Applicant 2 salary

Case number Applicant 2 employer name address and phone line 1 Applicant 2 employer name address and phone line 2 Applicant 2 previous marriages spouse name marriage place and date how when and where terminated line 1 Applicant 2 previous marriages spouse name marriage place and date how when and where terminated line 2 Applicant address Telephone City County State Zip Present marriage date Present marriage place Present marriage ceremony type Directions to house line 1 Directions to house line 2 Directions to house line 3 Directions to house line 4

Assets housing status

Rent Own

Mortgage or rent monthly amount Home owner's insurance Home owner's insurance face value Life hospital medical or other insurance include company and value line 1 Life hospital medical or other insurance include company and value line 2 Investments stocks and bonds include company and value line 1 Investments stocks and bonds include company and value line 2 Names of children born to or adopted by either applicant at any time Of what marriage Present age Residing with whom Names of children born to or adopted by either applicant at any time Of what marriage Present age Residing with whom Names of children born to or adopted by either applicant at any time Of what marriage Present age Residing with whom Names of children born to or adopted by either applicant at any time Of what marriage Present age Residing with whom Names of children born to or adopted by either applicant at any time Of what marriage Present age Residing with whom

Case number Names of other members of household including employees name column Names of other members of household age column Names of other members of household occupation column Names of other members of household relationship column Names of other members of household including employees name column Names of other members of household age column Names of other members of household occupation column Names of other members of household relationship column Names of other members of household including employees name column Names of other members of household age column Names of other members of household occupation column Names of other members of household relationship column Names of other members of household including employees name column Names of other members of household age column Names of other members of household occupation column Names of other members of household relationship column Reference 1 name Reference 1 address Reference 1 telephone Reference 2 name Reference 2 address Reference 2 telephone Reference 3 name Reference 3 address Reference 3 telephone Reference 4 name Reference 4 address Reference 4 telephone Reference 5 name Reference 5 address Reference 5 telephone

Have either of you ever applied to adopt a child from any source previously

Yes No

If so with whom when and where line 1 If so with whom when and where line 2 Disposition line 1 Disposition line 2

Have either of you applied for a divorce or sought marital counseling in the last three years

Yes No

Have any of you ever been arrested for or convicted of any criminal offense other than minor traffic violations

Yes No

If yes give details line 1 If yes give details line 2

Have either of you ever been confined in a mental institution psychiatric ward or under the care of a psychiatrist

Yes No

If yes give name address and telephone number of therapist and details of treatment line 1 If yes give name address and telephone number of therapist and details of treatment line 2

Case number Day sworn Month sworn Year sworn Attorney for applicants Typed or printed name Attorney address City state zip code Telephone number include area code Attorney registration number