FAMILIES ARE SPECIAL, INC.

P O BOX 5789 - 2200 Main Street

North Little Rock AR 72119

(501) 758-9184

Fax (501) 758-4704

E-mail fasas@Alltel.net

APPLICATION FOR PRE‑PLACEMENT ADOPTION HOME STUDY

Please complete with your spouse.

Last Name Home Phone Husband's Wk Phone Wife's Wk Phone

e-mail Fax

Street Address City State Zip

Directions to your home

NAME: WIFE HUSBAND

First Middle Maiden First Middle Last

BIRTH DATE BIRTH DATE

PLACE PLACE

RACE RACE

ANCESTRY/NATIONALITY ANCESTRY/NATIONALITY

RELIGION RELIGION

CHURCH/SYNAGOGUE ATTENDING CHURCH/SYNAGOGUE ATTENDING

OCCUPATION OCCUPATION

EMPLOYER EMPLOYER

ADDRESS ADDRESS

YOUR PARENTS NAMES YOUR PARENTS NAMES

First Middle Last First Middle Last

First Middle Last First Middle Last

WERE YOU ADOPTED? NO YES WERE YOU ADOPTED?NO YES

If yes, at what age and If yes, at what age and

circumstances? Circumstances

DATE AND PLACE OF PRESENT MARRIAGE

Date City State

HAVE EITHER OF YOU BEEN MARRIED BEFORE? YES NO

If no, move on to next section; if yes, complete following:

Date of Marriage Date Terminated

Terminated by: Divorce Death Annulment

Where Terminated:

City State County

Full Name of husband's

Ex‑spouse:

Ex‑Spouse's

Whereabouts:

City State County

Date of Marriage Date Terminated

Terminated by: Divorce Death Annulment

Where Terminated:

City State County

Full Name of wife's Ex‑spouse:

Ex‑Spouses'

Whereabouts:

City State County

DOES EITHER YOU OR YOUR SPOUSE HAVE ANY CHILDREN? NO YES

If no, move on to the next section; If yes please provide the following information:

Circle any adopted child(ren) and give the date adoption finalized.

CHILD'S NAME DOB SCHOOL GRADE IF THEY DON'T LIVE

OR OCCUPATION W/YOU, WHERE ARE THEY

ANY OTHER PERSON(S) LIVING WITH YOU OR FINANCIALLY DEPENDANT UPON YOU

NAME AGE OCCUPATION RELATIONSHIP TO YOU

Have you ever applied to another adoption agency or had a home study completed or served as foster parent? NO YES if Yes, list the

Name of Agency When?

ADDRESS ZIP PHONE

PERSONAL REFERENCES:

1. Minister/Priest/Rabbi

2. Neighbor/Friend

3. Wife's relative

4. Husband's relative

FINANCIAL:

Present Annual income from employment(husband)

Present Annual income from employment (wife)

Annual Income from investments or other sources

Present Value of Savings Accounts and Liquid Assets

Present debt excluding home mortgage

PRESENT RESIDENCE IS: Owned Rented Monthly Payment

If owned/buying: Present Market Value of Home and Property

Present Equity (market value less amount owed)

INSURANCE:

Life insurance amounts: (Husband) (Wife)

Amounts ________________________________________________________________

(Children) Amounts_______________________________________________________ _

(Health/Hospitalization)

Insurance:

Name and address of Attorney you will be using:

Name and address of Pediatrician/Physician you will be using:

At this time I/We are considering/committed to:

(a) Privately arranged domestic placement

(b) An ICPC Inter-State, Adoption from foster care

(c) An inter-country placement

(d) We have committed to agency.

(e) Birth country of child .

I/We have enclosed a $50 check (processing fee) with this application.

SIGNATURES:

Husband Date Social Security #

Wife Date Social Security #

R: 6/00