Adoption Form

Amy Hood Adoption Grant Application
A FEW QUICK CONSIDERATIONS

1. Applicants must be active members in good standing of a Cooperating Tennessee Baptist Church.

2. The home study must be complete before the application is submitted. Applications must be received no later than 30 days after the adoption is final.

3. Recipients of Amy Hood Adoption Grants are encouraged to reinvest in the Amy Hood Adoption Endowment in the future for the benefit of other adoptive parents and children.

4. History of the Amy Hood Adoption Endowment Fund - The Fund was established in January 2023 in memory of Amy Hood who died in October of 2022 at the age of 57. Amy and her husband Pat, pastor of LifePoint Church in Smyrna, TN, adopted three international children after their two biological children were grown and were known as strong adoption advocates. The fund was established with initial gifts from individuals and increased by allocations from the Golden Offering for TN Missions (GOTM), gifts from churches, and more individual gifts. The goal is to establish at least $1 million in the endowment.

For more information contact Beth Moore at bmoore@tnbaptist.org
PERSONAL INFORMATION
Husband's Full Name*
Age*
Wife's Full Name*
Age*
Mailing Address*
City*
State*
Zip Code*
Husband's Phone #*
Wife's Phone #*
Husband's Email Address*
example@example.com
Wife's Email Address*
example@example.com
Who is the primary contact?*

HusbandWife
Date of Marriage*

MonthDayYear
Date
Any prior divorce
Date of Divorce

MonthDayYear
Date
Husband's Employer*
Length of employment*
Wife's Employer*
Length of employment*
1. Names and ages of biological children in family:*
2. Have you adopted previously?*

YesNo
If yes, names/ages
3. Do you have a specific child identified already for this adoption?*

YesNo
If yes, Full Name
Age
Gender
4. Do you plan on adopting an older/special needs child?*
5. Church Name and Address*
6. Pastor's Name*
Church Phone*
Pastor's Cell Phone*
7. Do you profess Jesus Christ as personal Lord and Savior? (Father)*
Date Baptized (Father)*

MonthDayYear
Date
Do you profess Jesus Christ as personal Lord and Savior? (Mother)*
Date Baptized (Mother)*

MonthDayYear
Date
8. Details of Church Involvement (Father)*
9. Details of Church Involvement (Mother)*
Reference 1
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship*
Reference 2
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship*
Reference 3
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Relationship*
10. Specify any special financial considerations or circumstances:*
ADOPTION TESTIMONY
Tell us your adoption story (Husband)*
Tell us your adoption story (Wife)*
PERSONAL STATEMENT OF FAITH (Husband)
Please use 2-3 sentences to answer the following questions.
1. Describe your current relationship with God. (Husband)*
2. How do you use God's Word (the Bible) in your life? (Husband)*
3. Share your salvation testimony. (Husband)*
PERSONAL STATEMENT OF FAITH (Wife)
4. Describe your current relationship with God. (Wife)*
5. How do you use God's Word (the Bible) in your life? (Wife)*
6. Share your salvation testimony. (Wife)*
ADOPTION COSTS
Applicable Expenses
Agency Fees*
Child's Medical Exam*
Home Study*
Legal Fees*
Notarization/Authentication*
Orphanage Fees*
Travel*
Other Expense*
Other*
Estimated Total Adoption Cost*
Available Resources to Cover Adoption Costs
Personal Funds (savings, etc.)*
Employer Benefit (if available)*
Other Grants/Loans Received:
Name*
Amount*
Name*
Amount*
Name*
Amount*
Other source of funds (please specify)*
Amount*
Total Estimated Resources*
Deficit*
(Total Resources-Total Cost)
Additional Grants/Loans Applied For:
Name*
Amount*
Name*
Amount*
Name*
Amount*
STATEMENT OF NET WORTH
Cash*
Checking Accounts*
Savings Accounts*
Investment Accounts (other than retirement)*
Retirement Accounts*
Value of Autos*
Value of Home (if owned)*
Approximate Value of Household Items*
Value of other items you own not listed above (write description):
Name*
Amount*
Name*
Amount*
Name*
Amount*
Total Assets*
Liabilities
Outstanding Credit Card Balances*
Balances of Past Due Bills (excluding credit cards)*
Auto Loan Balances*
Home Mortgage Balance*
Any Other Amounts Owed (write description):
Name*
Amount*
Name*
Amount*
Name*
Amount*
Total Liabilities*
Net Worth*
(Assets - Liabilities)
CASH FLOW

(Both monthly and annual columns of cash flow must be completed.)
Income
Monthly Gross Salary/Wage (Household Totals)*
Annual Gross Salary/Wage (Household Totals)*
Monthly Investment Income*
Annual Investment Income*
Monthly Other Income*
(write description) Example - $2,000 (Rental House)
Annual Other Income*
(write description) Example - $24,000 (Rental House)
Monthly Other Income*
(write description) Example - $2,000 (Rental House)
Annual Other Income*
(write description) Example - $24,000 (Rental House)
Total Income Monthly*
Total Income Annual*
Monthly Church Giving*
Annual Church Giving*
Expenses/Payments
Monthly Taxes and other deductions from paychecks*
Annual Taxes and other deductions from paychecks*
Housing Costs:
Monthly Mortgage/Rent*
Annual Mortgage/Rent*
Monthly Property Taxes*
Annual Property Taxes*
Monthly Insurance*
Annual Insurance*
Monthly Utilities*
Annual Utilities*
Monthly Other Housing Costs*
Annual Other Housing Costs*
Monthly Telephone (include cell phones)*
Annual Telephone (include cell phones)*
Monthly Food*
Annual Food*
Monthly Clothing*
Annual Clothing*
Transportation Expenses:
Monthly Car Payment*
Annual Car Payment*
Monthly Car Insurance*
Annual Car Insurance*
Monthly Gas/Maintenance*
Annual Gas/Maintenance*
Monthly Other Transportation Expenses*
Annual Other Transportation Expenses*
Monthly Entertainment/Recreation*
Annual Entertainment/Recreation*
Monthly Medical Expenses*
(include health insurance if paid by you)
Annual Medical Expenses*
(include health insurance if paid by you)
Monthly Other Charitable Donations*
Annual Other Charitable Donations*
Monthly Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Annual Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Monthly Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Annual Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Monthly Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Annual Other Debt repayment*
(write description) Example - $2,000 (Rental House)
Total Expenses/Payments Monthly*
Total Expenses/Payments Annual*
Cash Flow Monthly*
(Total Income - Total Expenses/Payments)
Cash Flow Annual*
(Total Income - Total Expenses/Payments)
CONSENT FORM
1. Purpose

The undersigned agrees that this application is being made for the purpose of obtaining an adoption assistance grant. The undersigned further acknowledges that the willingness to accept an application is not any type of acknowledgement or representation that assistance will be granted or given.

2. Document Retention

The undersigned acknowledges and agrees that TBMB will retain this application and accompanying documents electronically in its Baptist Leadership Engagement and Service System (BLESS) for review by the assigned advisory body as established in the TBMB Directors' Organizational Manual, Article III, B.

3. Authorization and Release

The undersigned hereby authorizes any officer, employee, agent, representative or staff member of Tennessee Baptist Mission Board (TBMB) to obtain financial and personal information from any institution or individuals including but not limited to those individuals and institutions listed as references and made a part of this application. The undersigned further consents to the release of any information to any authorized TBMB employee or agent from any individual or financial institution listed on the attached list of references. The undersigned further authorizes any pastor, elder, minister or counselor included in the list of references to release to TBMB or its representatives personal information and opinions regarding the applicant's lifestyle, language, habits, truthfulness, parental fitness, and general moral biblical character.
Adoption Agency*
Case Worker*
Phone*
4. Limit of Liability

The undersigned acknowledges that TBMB has made no representation or warranty that financial aid or assistance will be furnished to the undersigned; and further acknowledges that TBMB shall have the sole discretion to accept or deny this application with or without cause. The undersigned further releases and holds TBMB harmless from any liability of any type or nature as a result of allowing the undersigned to submit this application.
5. Permission - The undersigned gives TBMB permission to use their story and/or photographs on TBMB's website, and/or printed material, with the purpose of helping families to adopt children. (Your answer does not have an effect on financial assistance.)*

YesNo
6. Funding Agreement

The undersigned parties acknowledge they are freely agreeing to the following terms and conditions as a requirement to participate in the adoption grant/loan process for TBMB:
1. We understand and accept that all funds in the Amy Hood Adoption Endowment and Adoption Fund are under the ultimate control of TBMB and TBMB is solely responsible for making all decisions regarding grants of any funds.
2. We understand the grants amounts from TBMB are impacted by available funding and the number of applicants. In no case will the grant amount exceed the documented financial need.
3. We understand that if we decide not to adopt or our adoption is disrupted for any reason we will contact TBMB immediately. Any funds that have not been disbursed for adoption related costs will be used to assist other families with the cost of adoption.
4. We agree to submit proper documentation as requested by TBMB for payment and/or reimbursements of any kind.
5. We understand, accept and agree to use any and all funds received exclusively for legitimate adoption expenses, including but not limited to agency fees, legal fees, etc.
6. We understand that all grants from the Amy Hood Adoption Endowment are made possible by the generosity of donors. We agree to consider reinvesting future gifts into the Amy Hood Adoption Endowment to help other families and children achieve the dream of adoption.
CONSENT FORM

(continued)
7. Attachments
1. Picture - Please include a photo of your current family, and if you have available, a picture of the child you desire to adopt.
2. Tax Return - Please include a copy of pages 1 and 2 of your Federal Tax Return for the last 2 years (1040 form). Please redact your Social Security numbers by marking through or covering them with tape before submitting.
3. Copy of completed Home Study
4. Letter from Pastor - A written reference from your pastor on church letterhead indicating his support of your adoption. Your pastor may email to bmoore@tnbaptist.org if he prefers the letter remain confidential.
File Upload*

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8. Signatures

We are providing this information to TBMB for their internal and confidential use. All information contained in this application is accurate to the best of our knowledge.
Adoptive Father Printed Name*
Adoptive Father Signature*

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Adoptive Father Date*

MonthDayYear
Adoptive Mother Printed Name*
Adoptive Mother Signature*

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Adoptive Mother Date*

MonthDayYear
Should be Empty:

Amy Hood Adoption Grant Application

PERSONAL INFORMATION

ADOPTION TESTIMONY

PERSONAL STATEMENT OF FAITH (Husband)

PERSONAL STATEMENT OF FAITH (Wife)

ADOPTION COSTS

STATEMENT OF NET WORTH

CASH FLOW

CONSENT FORM

CONSENT FORM