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ART Intake Information ART Representation Agreement Adoption Intake Information Adoption Representation Agreement

Adoption Intake Document

Please complete this form as thoroughly as possible.

* indicates required field

clear* Legal placement date:

*County of finalization:

*Is the adoption open or closed?

*Full birth name (as listed on the birth certificate):

*Full post-adoption name:

clear* Date of birth:

*Place of birth:

* Child’s address history for the past 5 years (i.e. address(es) and person(s) with whom the child has lived)

*Current address (including county):

*Duration at current address:

*Current Post office

*Most recent previous address

*Date and place of marriage:

* Names & ages of other children:

Complete Below Information for ADOPTIVE PARENT #1:

*FULL legal name of adoptive parent #1:

Maiden name (if applicable):

*Phone number:

clear* DOB:

*Age:

*Place of birth:

*Address at time of adoptive child’s birth:

*Email address:

*Employer/Occupation:

Complete Below Information for ADOPTIVE PARENT #2:

FULL legal name of adoptive parent #2:

Maiden name (if applicable):

Phone number:

clearDOB:

Age:

Place of birth:

Address at time of adoptive child’s birth:

Email address:

Employer/Occupation:

Complete Below Information for Birth Mother (ONLY PROVIDE IF CURRENTLY KNOWN-

Do not request this information from the agency or birth parents):

Biological mother’s full name & DOB:

Biological mother’s phone number:

Biological mother’s address:

Biological mother’s marital status and maiden name:

Did biological mother name a birth father:

Complete Below Information for Birth Father (ONLY PROVIDE IF CURRENTLY KNOWN-

Do not request this information from your agency or the birth parents):

Biological father’s full name & DOB:

Biological father’s phone number:

Biological father’s address:

Did biological father consent or sign a permanent surrender?:

Adoption Agency Information:

*Agency name and contact person:

*Agency contact’s phone number:

*Agency contact’s email:

*Total fees paid to adoption agency (round to nearest $1,000):

*Other adoption related expenses (round to nearest $100):

*IMPORTANT FINANCIAL NOTIFICATION*

Please be advised that you may be eligible for an adoption grant through the state of Ohio if you are completing any type of an adoption other than an adult or stepparent adoption. You must take advantage of this within one year of your adoption finalization. You may apply for the grant at adoptiongrant.ohio.gov under the state’s Ohio Adoption Grant Program.

All families may be able to receive a $10,000 grant for any adoption (except adult or stepparent adoptions), a $15,000 grant for a foster or kinship caregiver adoption or a $20,000 grant if the child(ren) is deemed to have special needs, be a part of a sibling set, etc.

You may also be eligible for a federal adoption tax credit in the amount of up to $14,800 for each child. It is income based. Unfortunately, I am unable to provide tax advice. Please contact an accountant to discuss any questions you may have about this tax opportunity.