The California AD 9 form is an Independent Adoption Questionnaire designed to gather essential information from prospective adoptive parents. This form plays a crucial role in the adoption process, ensuring that all relevant details about the petitioners and the child are documented. To begin your adoption journey, fill out the form by clicking the button below.
The California Ad 9 form is a crucial document in the independent adoption process, designed to gather comprehensive information about prospective adoptive parents. This form requires details such as the names of the petitioners, the child being adopted, and any adopted names. It also delves into personal backgrounds, asking for information on education, occupation, and financial stability, which are essential for assessing the suitability of the applicants. Additionally, the form includes sections addressing criminal history, previous marriages or partnerships, and any children from prior relationships. This thorough inquiry aims to ensure the safety and well-being of the child being adopted. Completing the Ad 9 form accurately and promptly is vital, as it plays a significant role in the adoption proceedings. Prospective parents should approach this process with care, as the information provided will be reviewed by the California Department of Social Services or a delegated county adoption agency. Understanding the importance of this form can help ease any apprehensions about the adoption journey.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE CASE NUMBER:
INDEPENDENT ADOPTION QUESTIONNAIRE
INFORMATION REQUIRED IN THE MATTER OF THE ADOPTION OF:
FIRST PETITIONER’S NAME:
SECOND PETITIONER’S NAME:
CHILD’S NAME:
CHILD’S ADOPTED NAME:
Dear Petitioner(s):
Complete this Independent Adoption Questionnaire (AD 9) and Adoption Questionnaire I (AD 4324) (to be filled out individually) and return them within one week.
Thank You.
__________________________________________________________________________
(NAME OF CDSS DISTRICT OFFICE OR DELEGATED COUNTY ADOPTION AGENCY)
(Please fill out as completely as possible, writing “NA” or “Unknown” where appropriate)
AD 9 (11/07)
PAGE 1 OF 12
I. FIRST PETITIONER’S INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
GENDER
BIRTHDATE
PLACE OF BIRTH
ETHNICITY
RACE
RELIGION
SOCIAL SECURITY NUMBER
DRIVER LICENSE NUMBER
EDUCATION
OCCUPATION
MONTHLY SALARY
-
(HIGHEST GRADE
COMPLETED)
$
NAME AND ADDRESS OF EMPLOYER
LENGTH OF EMPLOYMENT
WORK HOURS
WORK TELEPHONE NUMBER
(
)
ARE YOU A UNITED STATES CITIZEN?
DATE OF ARRIVAL IN U.S.
DATE OF ARRIVAL IN
■ YES ■ NO
CALIFORNIA
IF NATURALIZED
ARE YOU A PERMANENT RESIDENT?
ALIEN REGISTRATION NUMBER
DATE:
PLACE:
A-
NUMBER:
MILITARY SERVICE:
DATE OF SERVICE:
DATE OF DISCHARGE:
■ HONORABLE
■ DISHONORABLE
A.
CRIMINAL HISTORY
1)
Have you ever been arrested for an offense other than a traffic infraction?
■ YES
■ NO
If YES, please explain the charges and any convictions:
______________________________________________________________________________________________________
2)
Are you currently on probation or parole?
If YES, please explain the circumstance:
3)
Have you ever been investigated for allegations of child neglect or abuse?
If YES, please explain the circumstances:
4)
Have you ever been reported for allegations of domestic violence?
If YES, please explain the circumstances and outcome:
B.FORMER MARRIAGE(S)/REGISTERED DOMESTIC PARTNERSHIP(S) (RDP)
FULL NAME OF FORMER SPOUSE(S)/RDP(S)
(Give maiden name and current address)
WHERE
(License/Registration Issued in County/State)
MARRIAGE/RDP
(Date & Place)
DIVORCE/RDP TERMINATION
DEATH
PAGE 2 OF 12
C.CHILD(REN) BORN PRIOR TO CURRENT MARRIAGE/REGISTERED DOMESTIC PARTNERSHIP
FULL NAME OF CHILD
DATE OF
BIRTH
(Name & Address of School & Grade)
HEALTH CONDITIONS
IF ADOPTED
(Place, Date, Agency)
Have any of your children ever been arrested for an offense other than a traffic infraction?
Are any of your children currently on probation or parole?
Have any of your adult children ever been investigated for allegations of child neglect or abuse?
Have any of your adult children ever been reported for allegations of domestic violence?
D.
FAMILY HISTORY
HEALTH
RELATIVES’ NAMES
ADDRESS
(Highest Grade OCCUPATION
AGE
CONDITIONS
Completed)
(If Deceased)
FATHER
MOTHER
SIBLING
PAGE 3 OF 12
II. SECOND PETITIONER’S INFORMATION
FULL NAME OF FORMER SPOUSE/REGISTERED
DOMESTIC PARTNER
(License/Registration Issued in
County/State)
PAGE 4 OF 12
C. CHILD(REN) BORN PRIOR TO CURRENT MARRIAGE/REGISTERED DOMESTIC PARTNERSHIP
PAGE 5 OF 12
III. HOUSEHOLD INFORMATION
MAILING ADDRESS
CITY, STATE, ZIP
HOW LONG AT PRESENT ADDRESS
I. CELLULAR PHONE NUMBER
II. CELLULAR PHONE NUMBER
HOME TELEPHONE NUMBER
If you are a married or registered domestic couple:
If you are an unmarried couple:
DATE OF MARRIAGE/REGISTRATION:
LENGTH OF DOMESTIC PARTNERSHIP/RELATIONSHIP:
PLACE OF MARRIAGE/REGISTRATION:
HAVE YOU FILED A REGISTRATION OF DOMESTIC PARTNERSHIP WITH THE SECRETARY OF STATE?
(CITY, COUNTY AND STATE)
IF YES, DATE OF FILING:_______________________________________________
DESCRIBE YOUR HOME (INCLUDE NUMBER OF BEDROOMS & BATHROOMS):
DIRECTIONS TO YOUR HOME:
HAVE YOU EVER HAD ANY PREVIOUS ADOPTIVE PLACEMENT(S)?
■ NO IF YES, PLEASE DESCRIBE:
HAVE YOU EVER APPLIED WITH ANOTHER AGENCY?
IF YES, WHEN AND NAME OF AGENCY:
A.CHILD(REN) OF PETITIONER(S)
AD 9 (10/03)
PAGE 6 OF 12
B.OTHER MEMBERS OF THE HOUSEHOLD
FULL NAME
GENDER DATE OF BIRTH RELATIONSHIP TO FAMILY
1)Have any of these members of the household ever been arrested for an offense other than a
traffic infraction?
2) Are any of these members of the household currently on probation or parole?
3)Have any of these members of the household ever been investigated for allegations of child
neglect or abuse?
4) Have any of these members of the household ever been reported for allegations of domestic violence? ■ YES ■ NO If YES, please explain the circumstances and outcome:
IV. BIRTHPARENT/LEGAL PARENT INFORMATION
BIRTHMOTHER/LEGAL PARENT
BIRTHFATHER/LEGAL PARENT
NAME (LAST, FIRST, MIDDLE)
MAIDEN NAME OR ALIASES
ALIASES
ETHNICITY, RACE
TELEPHONE NUMBER
A.PLACEMENT DETAILS
DESCRIBE FULLY HOW YOU FIRST LEARNED OF THE CHILD, IF AND WHEN YOU MET THE BIRTHPARENTS/LEGAL PARENT, AND HOW YOU SECURED THIS CHILD FOR ADOPTION. INCLUDE SPECIFIC INFORMATION PERTAINING TO THE TRANSFER OF CUSTODY AND THE NAME OF ANY INTERMEDIARY INVOLVED.
PAGE 7 OF 12
B.EXPENSES RELATED TO ADOPTION
HOSPITAL
ADOPTION SERVICE
PROVIDER
PHYSICIAN
ATTORNEY
BIRTHPARENT/ LEGAL PARENT
OTHER
C.CONCERNING CHILD(REN) TO BE ADOPTED
CHILD #1
CHILD #2
NAME OF CHILD
DATE PLACED IN HOME
NAME OF HOSPITAL
ADDRESS OF HOSPITAL
ATTENDING PHYSICIAN
HEIGHT
WEIGHT
EYE COLOR
HAIR COLOR
HAS THE CHILD EVER BEEN KNOWN BY ANOTHER NAME?
CURRENT AGE
CURRENT WEIGHT
DO YOU BELIEVE THE CHILD WAS EXPOSED TO ALCOHOL OR DRUGS IN UTERO?
DO YOU BELIEVE OR SUSPECT THE CHILD WAS SUBJECTED TO
PHYSICAL, SEXUAL OR EMOTIONAL ABUSE OR NEGLECT PRIOR
TO PLACEMENT IN YOUR HOME?
IF YES, PLEASE PROVIDE DETAILS:
BRIEFLY DESCRIBE THE ADJUSTMENT OF YOUR CHILD(REN) TO YOUR HOME:
DESCRIBE CURRENT AND FUTURE PLANNED CHILD CARE ARRANGEMENTS:
DESCRIBE, IF ANY, RELIGIOUS TRAINING PLANS OF THE CHILD(REN):
D.SCHOOL INFORMATION (COMPLETE THIS SECTION IF CHILD(REN) ATTENDS SCHOOL)
NAME OF SCHOOL
SCHOOL ADDRESS
SCHOOL PHONE
GRADE LEVEL
REGISTERED NAME
TEACHER’S NAME
PAGE 8 OF 12
V.FINANCIAL INFORMATION
MONTHLY INCOME
GROSS WAGES
First Petitioner
. . . . . . . . . . . . . . . . . . . . . . . . .
. .
. . . . . . . . . . . . . . . . . . . . . . . .
$ __________________
Second Petitioner
NET WAGES
$ ______________________
OTHER INCOME (interest, property, dividends, etc.)
$ ___________________
TOTAL GROSS INCOME
MONTHLY EXPENSES
Housing (include taxes, insurance, & utilities)
Insurance
Food/Clothing
Legal Obligations (child support, alimony, etc.)
Extraordinary Expenses
MONTHLY CONSUMER DEBT PAYMENTS
ITEM
TERMINATION DATE
BALANCE DUE
MONTHLY PAYMENT
TOTAL
If you own your home, please indicate the following:
Purchase Price
Balance Due
$ _____________________
FINANCIAL ASSETS
Savings
Investments
Stocks, Bonds
Real Property
Other Resources
If you are self-employed or an employer cannot verify your income for some other reason, please attach a copy of your last year’s federal income tax return.
I/We filed both state and federal income tax returns last year.
■ YES ■ NO If NO, state reason: __________________________________________________________________________
I/We have had the occasion to file for bankruptcy.
If YES, state reason: _________________________________________________________________________
PLEASE USE THIS SPACE TO NOTE ANY ADDITIONAL FINANCIAL INFORMATION THAT YOU BELIEVE THE DEPARTMENT SHOULD BE AWARE OF:
PAGE 9 OF 12
VI. INSURANCE
Does your family have health and hospitalization insurance that covers all family members? ■ YES ■ NO
If YES, indicate the name of insurance carrier and address:____________________________________________________________
___________________________________________________________________________________________________________
Name and address of family physician:____________________________________________________________________________
Name and address of pediatrician: _______________________________________________________________________________
What provisions for medical care will be provided for the child(ren)?_____________________________________________________
Check the types of insurance coverage your family has and briefly describe each coverage.
■Life Insurance: __________________________________________________________________________________________
■Disability Insurance: ______________________________________________________________________________________
■Automobile Insurance: ____________________________________________________________________________________
■Renters/Home Owners Insurance: ___________________________________________________________________________
■Other Policies: __________________________________________________________________________________________
NOTE: California law (Section 1373(c) of the Health and Safety Code, and Sections 10119, 10112, and 11512.1 of the Insurance Code) requires that effective January 1, 1988, all health care service plans provide accident and sickness coverage to each minor child placed for adoption from and after the moment the child is placed in the physical custody of the covered subscriber or enrollee of adoption.
PAGE 10 OF 12
Filling out the California Ad 9 form is an important step in the adoption process. This form collects essential information about the petitioners and their backgrounds. After completing the form, ensure it is returned within the specified timeframe to the appropriate agency.
The California Ad 9 form, also known as the Independent Adoption Questionnaire, is a document required by the California Department of Social Services. It gathers essential information from individuals looking to adopt a child. The form must be completed by both petitioners involved in the adoption process. It covers various topics, including personal details, criminal history, family background, and information about any children from previous relationships.
Both petitioners who are planning to adopt must fill out the Ad 9 form. This includes anyone who is legally pursuing the adoption of a child, whether they are married, in a domestic partnership, or single. Each petitioner must provide detailed personal information, including their background, employment history, and any past legal issues. This ensures that the adoption agency has a complete understanding of the individuals involved in the adoption.
The completed Ad 9 form should be submitted to the designated California Department of Social Services district office or the delegated county adoption agency. It is important to return the form within one week of receiving it. If any section does not apply to you, write "NA" or "Unknown" where appropriate. This helps ensure that the agency has accurate and complete information to process the adoption.
If any issues arise during the completion of the Ad 9 form, such as a criminal history or allegations of child neglect, it is crucial to provide honest and thorough explanations. The adoption agency will review this information carefully. Depending on the circumstances, they may conduct further investigations or request additional documentation. Transparency is key, as it helps the agency assess the suitability of the petitioners for adoption.
Incomplete Information: Many individuals fail to provide all the required details. This includes missing names, dates, or other critical information that can delay the adoption process.
Incorrect Dates: Some applicants mistakenly enter the wrong dates for events such as birth, marriage, or previous adoptions. Accuracy is crucial, as discrepancies can lead to complications.
Omitting Criminal History: Failing to disclose any arrests or convictions, even if they seem minor, can have serious repercussions. Honesty is essential in this section.
Neglecting Child Information: Parents sometimes overlook providing details about their biological or adopted children. This information is vital for the assessment process.
Ignoring the Signature Requirement: Some forget to sign the form or have both petitioners sign when required. An unsigned form can lead to delays or rejections.
Misunderstanding Citizenship Questions: Applicants may misinterpret questions about citizenship status. Providing incorrect answers can complicate the application process.
Failure to Meet Submission Deadlines: The form requires timely submission. Missing the one-week deadline can result in the need to start over, causing unnecessary delays.
The California AD 9 form is a crucial document in the independent adoption process, gathering essential information about the prospective adoptive parents. Various other forms and documents complement this form, ensuring that all necessary information is collected and evaluated. Below is a list of related documents often used in conjunction with the California AD 9 form.
These forms collectively contribute to a comprehensive understanding of the adoption scenario, ensuring that all parties are informed and prepared for the responsibilities that come with adoption. Proper completion and submission of these documents facilitate a smoother adoption process in California.
The California Adoption Questionnaire I (AD 4324) is closely related to the AD 9 form. Both documents serve to gather essential information about prospective adoptive parents. The AD 4324 focuses on individual details, requiring each petitioner to provide personal background, including education, employment, and any legal issues. This individual approach complements the AD 9, which collects similar information but does so in a joint format, making it easier for the agency to evaluate both petitioners simultaneously.
The Home Study Report is another document that parallels the AD 9. This report is typically conducted by a social worker and assesses the suitability of the adoptive home. Like the AD 9, it involves gathering detailed information about the prospective parents, including their financial stability, emotional readiness, and overall family dynamics. Both documents aim to ensure that the child is placed in a safe and nurturing environment.
The Adoption Placement Agreement is also similar to the AD 9 in that it outlines the responsibilities and expectations of both the adoptive parents and the agency. While the AD 9 collects background information, the Placement Agreement formalizes the adoption process and ensures that all parties understand their roles. This agreement is essential for protecting the interests of the child and ensuring a smooth transition into the adoptive home.
The Foster Care Application shares similarities with the AD 9, as both require detailed personal information from individuals seeking to provide care for children. The Foster Care Application focuses on those who wish to foster children temporarily, while the AD 9 is specific to adoption. However, both documents evaluate the caregivers' backgrounds, including criminal history and family dynamics, to ensure the safety and well-being of the children involved.
The Child Welfare Services (CWS) Referral Form is another document that aligns with the AD 9. This form is used when there are concerns about a child's safety and welfare. While the AD 9 focuses on potential adoptive parents, the CWS Referral Form gathers information about the child’s current living situation and any risk factors. Both documents play critical roles in safeguarding children and ensuring that they are placed in suitable environments.
The Consent for Adoption form is also relevant. This document is signed by birth parents to relinquish their parental rights and allow the adoption to proceed. While the AD 9 collects information from prospective adoptive parents, the Consent for Adoption is a necessary legal step that affirms the birth parents' decision. Both documents reflect the serious commitment involved in the adoption process and the importance of informed consent.
The Post-Adoption Agreement is similar in that it addresses ongoing relationships after the adoption is finalized. While the AD 9 focuses on the initial assessment of adoptive parents, the Post-Adoption Agreement outlines expectations for contact between birth and adoptive families. This document acknowledges the emotional complexities of adoption and aims to create a supportive framework for all parties involved.
The Adoption Disclosure Form is another document that shares similarities with the AD 9. This form provides information about the child's background, including medical history and any known family connections. While the AD 9 gathers information from the adoptive parents, the Adoption Disclosure Form ensures that the adoptive parents receive vital information about the child’s history, which can be crucial for their future well-being.
Lastly, the Interstate Compact on the Placement of Children (ICPC) form is relevant for families considering adoption across state lines. This form ensures that all legal requirements are met when placing a child in a different state. While the AD 9 focuses on the adoptive parents' qualifications, the ICPC form addresses the legal complexities involved in interstate adoptions, ensuring that the child's best interests are prioritized throughout the process.
When filling out the California AD 9 form, it's important to follow specific guidelines to ensure accuracy and completeness. Below are nine things to do and avoid.
Misconception 1: The AD 9 form is only for married couples.
This form is applicable to all individuals pursuing independent adoption, regardless of marital status. Both single individuals and couples can complete the form to provide necessary information about themselves and the child they wish to adopt.
Misconception 2: Completing the AD 9 form guarantees approval for adoption.
Filling out the AD 9 form is just one step in the adoption process. Approval depends on various factors, including background checks and home studies. The form serves to gather information, not to guarantee a successful adoption.
Misconception 3: The information provided in the AD 9 form is confidential and cannot be accessed.
While personal information is collected, certain details may be shared with relevant agencies or parties involved in the adoption process. It is important to be aware that some information may not remain completely private.
Misconception 4: The AD 9 form is not important and can be filled out carelessly.
Accuracy and thoroughness are crucial when completing the AD 9 form. Incomplete or incorrect information can delay the adoption process or even lead to denial. Careful attention to detail is essential.
The California AD 9 form is a crucial document in the independent adoption process. Here are key takeaways to consider when filling it out and using it: