new adoption home study application 06142020

ADOPTION HOME STUDY APPLICATION

Main Office Location Monroe County Office 391 Broad St. NW #201 210 Railroad St. Cleveland TN 37311 Sweetwater TN 37874 423-790-3747 Ext. 1 423-790-3747 Ext. 2

www.solomonfamilysolutions.com

Today’s Date: _______________

Applicant’s Full Legal Name: ______________________________________________________

All other names or alias used (including maiden name): __________________________________________________________________________________________________________________________________________________________________________

Email address: ___________________________ Cell phone: ______________________________

Date of Birth: _________________ City and State of Birth: _____________________________

Social Security Number: ______________________ Gender: _____________________________

Race: _______________ Religious Identification, if any:______________________

Highest Level of Education Completed: ______________________________________________

Marital Status: Single Married Divorced Widowed

If married, date of marriage: ____________ If divorced, date of divorce: _________________

Employment Status: Full Time Part time Unemployed Student

If employed, name of employer: ______________________________________________

Address of employer: __________________________________________________________________________________________________________________________________________________________________________

Occupation/Title:___________________________________________________________________

How long have you been with this employer? 0-11 months 1-5 years 5+years

If less than 5 years, where did you previously work? __________________________________________________________________________________________________________________________________________________________________________

What is your gross annual income? _________________________________________________

Co-Applicant’s Full Legal Name: ___________________________________________________

All other names or alias used (including maiden name): __________________________________________________________________________________________________________________________________________________________________________

Email address: ___________________________ Cell phone: ______________________________




Date of Birth: _________________ City and State of Birth: _____________________________

Social Security Number: ______________________ Gender: _____________________________

Race: _______________ Religious Identification, if any: _____________________

Highest Level of Education Completed: ______________________________________________

Marital Status: Single Married Divorced Widowed

If married, date of marriage: ____________ If divorced, date of divorce: _________________

Employment Status: Full Time Part time Unemployed Student

If employed, name of employer: ______________________________________________

Address of employer: __________________________________________________________________________________________________________________________________________________________________________

Occupation/Title:___________________________________________________________________

How long have you been with this employer? 0-11 months 1-5 years 5+years

If less than 5 years, where did you previously work? __________________________________________________________________________________________________________________________________________________________________________

What is your gross annual income? _________________________________________________

Current Home Address: __________________________________________________________________________________________________________________________________________________________________________

How long have you been residing at this home? ______________________________________

If less than 5 years, please list previous address: __________________________________________________________________________________________________________________________________________________________________________

How long have you resided in the State of TN? _______________________________________

Please list all other adults (18+ years old) living in the home (not including applicant(s)):

Full Legal Name: _________________________________________________DOB: _____________

Relationship to applicant(s): _________________________________________________________








(Use a separate sheet of paper to list additional adults living in the home)

Please list all the children in the home:











(Use a separate sheet of paper to list additional children living in the home)

Please list all the pets in the home:

Name: ______________________________________________________________________________

Type/Breed: __________________ Age: __________________ Indoor or Outdoor: __________

History of biting humans/Dangerous? Yes No If yes, please explain: __________________________________________________________________________________________________________________________________________________________________________

Current immunization records? Yes No N/A

Name: ______________________________________________________________________________






Current immunizations? Yes No N/A

Name: ______________________________________________________________________________



Current immunizations? Yes No N/A

Are there firearms and/or other weapons in the home? Yes No

If yes, are they in a locked safe or cabinet out of reach of children? Yes No

IS THE APPLICANT AND/OR CO-APPLICANT CURRENTLY CHARGED WITH, OR EVER BEEN CONVICTED OF, PLACED ON PROBATION OR RECEIVED A SUSPENDED SENTENCE IN TENNESSEE OR ANY OTHER STATE FOR:

ANY CRIMES INVOLVING CHILDREN YES NO

ANY CRIME OF VIOLENCE AGAINST ANOTHER PERSON YES NO

POSSESSION, SALE, OR MANUFACTURING OR TRANSPORTATION OF ILLEGAL DRUGS YES NO

ANY OTHER CRIMES YES NO

IF ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

IS THERE ANY OTHER INFORMATION YOU WISH TO DISCLOSE? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




Please provide five (5) personal references (2 Relatives and 3 Non-relatives)

Name: _____________________________________________________________________________

Address: __________________________________________________________________________________________________________________________________________________________________________

Phone Number: ___________________________ Email: __________________________________

Relationship to Applicant(s): ________________________________________________________

Name: _____________________________________________________________________________

Address: __________________________________________________________________________________________________________________________________________________________________________



Name: _____________________________________________________________________________

Address: __________________________________________________________________________________________________________________________________________________________________________



Name: _____________________________________________________________________________

Address: __________________________________________________________________________________________________________________________________________________________________________



Name: _____________________________________________________________________________

Address: __________________________________________________________________________________________________________________________________________________________________________






By signing below, you are authorizing Solomon Family Solutions to contact references listed on the application and authorize listed references to provide requested information to Solomon Family Solutions.

Further, your signature affirms that the information provided in this application for an adoption home study is correct and complete to the best of your knowledge. By signing below, you are also acknowledge that should the investigation show falsification or misrepresentation, you will no longer be considered for the home study and may disqualify you from future consideration of becoming an adoptive parent. You further understand that the information provided on this application and the status of your approval may be shared with other placement agencies.

__________________________________________ _________________________ Applicant Signature Date __________________________________________ _________________________ Co-Applicant Signature Date

NEXT STEPS

1) Once application is fully completed and signed, please return to Solomon Family Solutions Attn: Andrea Chase via email [email protected]

2) Remit payment online via solomonfamilysolutions.com. A minimum 25% of your total adoption fee is due to start the adoption home study process. Household Annual income will be verified during the adoption home study investigation via paystubs and federal tax returns.

3) Once application and payment are received, you will receive further instructions, forms, and a checklist to move forward in your adoption home study journey via email. Please make sure your email is clearly printed on this application. Please allow 48 – 72 hours to receive this email from our office. If you do not receive an email, check spam folder (sometimes our emails go to spam ) if it’s not there then do not hesitate to contact Andrea Chase via email [email protected] or via text message 423-599-9968

Household Annual Income Total Fee 25%

$0-$30,000 $650 $162.50

$30,001-$50,000 $800 $200

$50,001-+ $1,000 $250

new adoption home study application 06142020

Documents