Giampolo Law Group Adoption Questionnaire
Individual Parties Background Information
1st Petitioner
Gender
M
F
F-M
M-F
Pronouns
Birthdate
Social Security #
Drivers License Number
Highest Grade Level
Occupation
Name of Employer
Work Address
Monthly Salary
Length of Employment
Work Telephone
E-mail Address
Job Title
Home Address
Home Phone
Cell Phone
Place of Birth
Nationality
Ethnicity
Race
Residency Status
Alien Registration Number
Date of Arrival in US
Military Service?
Religious Affiliation?
Please list all previous addresses in the last 5 years
2nd Petitioner
Gender
M
F
F-M
M-F
Pronouns
Birthdate
Social Security #
Drivers License Number
Highest Grade Level
Occupation
Name of Employer
Employer Address
Monthly Salary
Length of Employment
Work Telephone
E-mail Address
Job Title
Home Address
Home Phone
Cell Phone
Place of Birth
Nationality
Ethnicity
Race
Residency Status
Alien Registration Number
Date of Arrival in US
Military Service?
Religious Affiliation?
Home Residence Address
Please list all previous addresses in the last 5 years
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Marriage/Registered Domestic Partnerships (RDP)
Type of Registration
Where License/Registration was issued(city,county,state)
Date
Residency Status
If Cohabitating, How Long?
Dating Anniversary
Former Marriage(s)/Registered Domestic Partnerships (RDP)
Petitioner 1
Full Name of Former Spouse
Where License/Registration was issued
Date and Place
Termination Date
Address
Phone Number
Email
Status of Relationship
Full Name of Former Spouse
Where License/Registration was issued
Date and Place
Termination Date
Address
Phone Number
Email
Status of Relationship
Petitioner 2
Full Name of Former Spouse
Where License/Registration was issued
Date and Place
Termination Date
Address
Phone Number
Email
Status of Relationship
Full Name of Former Spouse
Where License/Registration was issued
Date and Place
Termination Date
Address
Phone Number
Email
Status of Relationship
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Child(ren) Born Prior to Current Marriage/RDP
Petitioner 1
Full Name of Child
Date of Birth
Health Condition
If adopted, Place & Date
Full Name of Child
Date of Birth
Health Condition
If adopted, Place & Date
Petitioner 2
Full Name of Child
Date of Birth
Health Condition
If adopted, Place & Date
Full Name of Child
Date of Birth
Health Condition
If adopted, Place & Date
Household Information
Mailing Address
City,State,Zip
Length of Time at Address
Home Telephone
Date
E-mail Address
Job Title
Child(ren) of Petitioners
Full Name of Child
Date of Birth
If adopted, Place & Date
If adopted, Agency
Agency Address
Agency Phone Number
Education (School Name & Grade Level)
Full Name of Child
Date of Birth
If adopted, Place & Date
If adopted, Agency
Agency Address
Agency Phone Number
Education (School Name & Grade Level)
Other Members of Household
Full Name
Relation
Date of Birth
Occupation
Full Name
Relation
Date of Birth
Occupation
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Birth Parent/Legal Parent Information
Birth Mother Name
Maiden Name / Alias
Ethnicity, Race
Birthdate
Home Address
Telephone
Occupation
If Artificial Insemination procedures were used please describe here. (Include agency name, method)
Describe the rights of the Natural Mother here:
Medical Agency Name
Address
Phone Number
Birth Father Name
Other Names/Alias
Ethnicity, Race
Birthdate
Home Address
Telephone
Occupation
If Artificial Fertilization methods were used please describe the procedure here:
If cryobank methods were used, and the donor remains anonymous, please identify which facility or enterprise was used here along with the name of the physician:
Describe the rights of the Natural Father here:
Medical Agency Name
Address
Phone Number
Concerning Child(ren) to be Adopted
Child One
Gender
M
F
Birthdate
Place of Birth
Date Brought Home
Name of Hospital
Physician
Height
Weight
Eye Color
Hair Color
Social Security #
Child Two
Gender
M
F
Birthdate
Place of Birth
Date Brought Home
Name of Hospital
Physician
Height
Weight
Eye Color
Hair Color
Social Security #
Religious Affiliation
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