The California Ad 9 form is an Independent Adoption Questionnaire that gathers essential information from prospective adoptive parents. This form is crucial for the adoption process, as it helps the California Department of Social Services assess the suitability of applicants. Completing the Ad 9 form accurately and promptly is vital for a smooth adoption journey.
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The California AD 9 form, officially known as the Independent Adoption Questionnaire, serves as a critical tool for prospective adoptive parents. This comprehensive document collects essential information about the petitioners, including personal details such as names, birthdates, and social security numbers. It also delves into the backgrounds of both petitioners, requiring disclosures on education, employment, and military service. The form addresses sensitive topics, such as criminal history, allegations of child neglect or abuse, and domestic violence, ensuring that all relevant factors are considered in the adoption process. Additionally, it requests information about any prior marriages or registered domestic partnerships, as well as details regarding children from those relationships. Family history, including health conditions and educational backgrounds of relatives, is also documented. Completing the AD 9 form accurately and thoroughly is essential, as it plays a significant role in evaluating the suitability of the petitioners for adoption. The California Department of Social Services emphasizes the importance of returning this form promptly, typically within one week, to facilitate a smooth adoption process.
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
After gathering the necessary information, you are ready to fill out the California AD 9 form. This form requires detailed personal information about both petitioners and their family history. Ensure that all fields are completed accurately to avoid delays in the adoption process.
What is the California AD 9 form?
The California AD 9 form, also known as the Independent Adoption Questionnaire, is a document required by the California Department of Social Services for individuals looking to adopt a child independently. It collects essential information about the petitioners, including personal details, criminal history, and family background. Completing this form is a crucial step in the adoption process.
Who needs to fill out the AD 9 form?
Both petitioners in an adoption must complete the AD 9 form. This includes all individuals who are seeking to adopt a child. Each petitioner must provide their personal information, background details, and any relevant history that could impact the adoption process.
What information is required on the AD 9 form?
The AD 9 form requires a variety of information, including personal details such as names, birthdates, and addresses. It also asks about education, employment, and income. Additionally, the form inquires about criminal history, any prior marriages or domestic partnerships, and information about children from previous relationships. This comprehensive data helps assess the suitability of the petitioners for adoption.
How should the AD 9 form be submitted?
Once completed, the AD 9 form should be returned to the designated California Department of Social Services district office or delegated county adoption agency. It is important to submit the form within one week of receiving it to ensure a smooth continuation of the adoption process.
What happens if there are issues in my background?
If there are any concerns in your background, such as criminal history or allegations of child neglect or abuse, it’s crucial to be transparent on the form. Providing clear explanations can help address potential issues early in the process. The adoption agency will review your background as part of their assessment, and honesty is essential for building trust.
Can I get help with filling out the AD 9 form?
Yes, assistance is available for filling out the AD 9 form. Many adoption agencies offer guidance through the process. You can also consult with legal professionals who specialize in adoption to ensure that all information is accurately provided and to address any questions you may have.
What is the next step after submitting the AD 9 form?
After submitting the AD 9 form, the adoption agency will review your application and may schedule interviews or home visits as part of the evaluation process. They will also require the completion of additional forms, such as the Adoption Questionnaire I (AD 4324). Stay in communication with the agency to understand the next steps and any further documentation needed.
Filling out the California AD 9 form can be a challenging task. One common mistake people make is not providing complete information. Each section requires specific details about the petitioners and their families. If any fields are left blank, it can delay the adoption process. Always ensure that every question is answered, even if that means writing “NA” or “Unknown” where applicable.
Another frequent error is neglecting to double-check the names and dates. Spelling mistakes or incorrect dates can create confusion. For instance, if a child's name is misspelled or a birthdate is wrong, it may lead to complications later on. Accuracy is crucial, so take a moment to review all entries before submitting the form.
Many people also fail to provide adequate explanations for any “yes” answers in the criminal history section. If there are arrests, probation, or investigations, detailed explanations are necessary. Simply marking “yes” without context can raise red flags. Providing clear and honest explanations helps the reviewing agency understand the circumstances better.
Some petitioners overlook the requirement for both partners to complete their sections individually. Each petitioner must fill out their own AD 9 form. Skipping this step can lead to incomplete applications and further delays. Make sure that both individuals involved in the adoption process take the time to fill out their respective forms thoroughly.
Finally, failing to submit the forms on time is a significant mistake. The instructions clearly state that the AD 9 and the Adoption Questionnaire I (AD 4324) should be returned within one week. Late submissions can hinder the adoption timeline. Set a reminder to ensure that all paperwork is sent promptly.
The California Ad 9 form is an essential document in the independent adoption process, serving as a comprehensive questionnaire for prospective adoptive parents. Several other forms and documents are commonly used alongside the Ad 9 to ensure a smooth and legally compliant adoption process. Below is a brief overview of these documents.
These documents collectively contribute to a thorough and transparent adoption process, safeguarding the interests of all parties involved, especially the child. Understanding each form's purpose and requirements can help prospective adoptive parents navigate the complexities of adoption more effectively.
The California AD 9 form serves as an essential document in the adoption process, gathering vital information from prospective adoptive parents. Several other documents share similarities with the AD 9 form, particularly in their purpose and the type of information they collect. Here’s a breakdown of seven such documents:
Filling out the California AD 9 form can be a crucial step in the adoption process. To ensure that your application is processed smoothly, here are some important do's and don'ts to keep in mind.
By following these guidelines, you can enhance the likelihood of a successful submission. Good luck with your adoption journey!
This form is intended for any two individuals looking to adopt, regardless of their marital status. Whether you are married, single, or in a domestic partnership, you can complete the form.
The form does require you to disclose your criminal history, but having a past does not automatically disqualify you from adopting. Each case is evaluated individually.
Filling out the AD 9 form is a required step in the independent adoption process in California. It provides necessary information for your adoption case.
It is important to return the completed form within one week of receiving it. Timely submission helps keep the adoption process moving smoothly.
The information you provide on the AD 9 form is kept confidential and is used solely for the purpose of evaluating your adoption application.
Having children does not disqualify you from adopting. In fact, the form asks for information about your existing children to understand your family dynamics better.
Both petitioners must complete their sections of the form. Each individual's background and circumstances are important for the adoption evaluation.
The AD 9 is one of several forms required in the adoption process. You will also need to complete the Adoption Questionnaire I (AD 4324) and possibly other documents.
If a question does not apply, you should write "NA" or "Unknown" instead of leaving it blank. This helps clarify your situation for the reviewers.
The form also includes sections about your criminal history, family background, and any previous marriages or partnerships. This comprehensive approach helps assess your suitability as an adoptive parent.