Known Sperm Donor Agreement Intake Questionnaire

Known Sperm Donor Agreement Intake Questionnaire

Burroughs Law Office, P.C. (dba) Frugal Legal Services
The following are explanations of some common terms used throughout this intake questionnaire:

1. Recipient: This is the individual who is attempting to create a child and to become the child's parent. They are receiving the sperm donation from the donor.

2. Recipient's Spouse: This is the person who is lawfully married to the recipient.

3. Donor: A donor is an individual who produces sperm used for assisted reproduction, whether or not for consideration.

4. Donor's Spouse: This is the person who is lawfully married to the donor.
Information About Recipient

The following questions pertain to the person who is receiving the donor sperm.
What is the recipient's complete legal name? (complete names only - no initials)

First NameMiddle NameLast NameSuffix
What are the recipient's pronouns?

she/her/hershe/him/histhey/them/theirsOther
What is the recipient's email address?
example@example.com
What is the recipient's phone number?
Please enter a valid phone number.
What is the recipient's residential address below. (No PO Boxes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the recipient's date of birth?

MonthDayYear
Date
Is the recipient married?

YesNo
Information About the Recipient's Spouse

The following questions pertain to the person who is married to the recipient.
Select the best word that describes the recipient's spouse's role in the marital relationship.

HusbandWifeSpouseOther
What is the recipient's spouse's complete legal name? (complete names only - no initials)

First NameMiddle NameLast NameSuffix
What is the recipient's spouse's residential address below. (No PO Boxes.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the recipient's spouse's email address?
example@example.com
What is the recipient's spouse's phone number?
Please enter a valid phone number.
What is the recipient's spouse's date of birth?

MonthDayYear
Date
Is the recipient's spouse's residential address the same as the recipient's address?

YesNo
Information About the Donor

The following questions pertain to the person who is donating their sperm.
What is the donor's complete legal name? (complete names only - no initials)

First NameMiddle NameLast NameSuffix
What is the donor's residential address? (No PO Boxes.)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the donor's email address?
example@example.com
What is the donor's phone number?
Please enter a valid phone number.
FYI: Reimbursement and Compensation Provisions

Reimbursement and compensation is typically not provided for private, known sperm donors. However, the following information is provided regarding reimbusrement and compensation for surrogacy contracts for information purposes only. Please note that a contract is void and unenforceable if compensation is paid.

REIMBURSEMENT

1. A donor may receive reimbursement for economic losses resulting from the retrieval or storage of gametes and incurred after the donor has entered into a valid agreement in a record to be a donor.

2. Economic losses occurring before the donor has entered into a valid agreement in a record to be a donor may not be reimbursed except as provided for in the next paragraph.

3. Premiums paid for insurance against economic losses directly resulting from the retrieval or storage of gametes for donation may be reimbursed, even if such premiums have been paid before the donor has entered into a valid agreement in a record, so long as such agreement becomes valid and effective before the gametes are used in assisted reproduction in accordance with the agreement.

COMPENSATION

1. The consideration, if any, paid to a donor must be reasonable and negotiated in good faith between the parties.

2. Compensation may not be conditioned upon the purported quality or genome-related traits of the gametes.

3. Compensation may not be conditioned on actual genotypic or phenotypic characteristics of the donor or the child.
Is the donor married?

YesNo
What is the donor's spouse's complete legal name? (complete names only - no initials)

First NameMiddle NameLast NameSuffix
Will the donor be required to submit for any screening before providing their donation (examples may include genetic testing and sexually transmitted diseases)?

YesNo
Select any of the following screening that is required of the donor before providing their donation to the recipient (select all that apply):

Genetic testing (cystic fibrosis, sickle cell disease, thalassemia, hemoglobin related to blood disorders, etc.)Chromosomal abnormalitiesSexually transmitted infectionsMedical history of the donor as well as a history of their children, siblings, parents, and grandparents for up to four generations backPhysical examination to include donor's general healthOther
Who will pay for the donor screening?

RecipientRecipient's SpouseDonorOther
Do the parties intend to employ a physician/third party to collect the sperm and to perform the artificial insemination?

YesNo
Information About the Intended Physician/Third Party

The following questions pertain to the intended physician/third party employed to collect the sperm specimen and to perform the artificial insemination.
What is the physician's/third party's complete legal name?

PrefixFirst NameMiddle NameLast NameSuffix
Is the physician/third party authorized by the recipient to use fresh or frozen semen from the donor?

YesNo
Please provide any additional information or ask any questions in the space provided.
Should be Empty:

Known Sperm Donor Agreement Intake Questionnaire

Information About Recipient

Information About the Recipient's Spouse

Information About the Donor

FYI: Reimbursement and Compensation Provisions

Information About the Intended Physician/Third Party