Free STATE OF MINNESOTA - Minnesota

State of Minnesota
County Judicial District: Court File Number: Case Type:

District Court
Adoption ­ Stepparent

In the Matter of the Petition of: , Petitioner/Parent and , Petitioner/Stepparent To Adopt: , (child's current name) , (child's current name) , (child's current name)

STEPPARENT ADOPTION AFFIDAVIT CHECKLIST IF POST-PLACEMENT ASSESSMENT WAIVED

State of Minnesota County of Petitioners,
[stepparent's name] , being first

) ) SS )
[parent's name] and duly sworn upon oath state as follows:

1.

This Stepparent Adoption Affidavit Checklist is being filed in lieu of the Post-Placement Assessment Report, which the Petitioners have requested that the Court waive. Petitioners' full names are ___________________________________ [stepparent's name].

2.

[parent's name]

and

3.

Petitioners were married on of
[city] , County of [state] .

[date of marriage] in the City of [county] , State

ADO210

State

ENG

Rev 5/08

www.mncourts.gov/forms

Page 1 of 4

No. 1. 2. 3. 4. 5. 6. 7. 8.

Question Is this adoption being contested by the absent birth parent? Is the child you are seeking to adopt over 14 years of age? If "yes", the child must consent to the adoption. Are there any minor brothers and/or sisters of the child being adopted who are not included in the adoption request? Have you ever been divorced or had a marriage dissolved? Do you have any child from any prior marriages or relationships living in the home with you? Are you under a court order for payment of child support in Minnesota or any other state? Has any action for mental commitment or involuntary hospitalization been taken against you in any state? Have you or any member of your family participated in family support services (i.e., family counseling, individual therapy, parenting classes, etc.) either voluntarily or involuntarily? Have you been involved in involuntary welfare intervention in the life of your family in the past 5 years? Have you ever been the subject of a report for child dependency/neglect, child abuse, sexual abuse or domestic violence in Minnesota or any other state? Have you ever been arrested or convicted of a felony or gross misdemeanor (including DWI, sex offense or assault charges)? Has involvement with drugs or alcohol brought you into contact with any of the following systems: counseling, treatment, hospitalization, law enforcement or social services?

Parent Stepparent Response Response Yes No Yes No Yes Yes Yes Yes Yes Yes Yes No No No No No No No Yes Yes Yes Yes Yes Yes Yes No No No No No No No

9. 10.

Yes Yes

No No

Yes Yes

No No

11. 12.

Yes Yes

No No

Yes Yes

No No

13. If any of the above questions are answered "Yes," Petitioners have attached to this Affidavit a separate sheet of paper, signed by both Petitioners in the presence of a notary public, providing a detailed explanation about such response. 14. Please list where you have lived during the last five years, including street address, city, state, zip code, county, and approximate dates):

Address City State Dates

ADO210

State

ENG

Rev 5/08

www.mncourts.gov/forms

Page 2 of 4

Address City State Dates

Address City State Dates

Address City State Dates

Further affiants sayeth not except that this affidavit is made in good faith in support of their motion for waiver of the requirements of the one year residency requirement.

Dated: Petitioner/Parent (sign only in front of notary public) Dated: Petitioner/Stepparent (sign only in front of notary public)

ADO210

State

ENG

Rev 5/08

www.mncourts.gov/forms

Page 3 of 4

VERIFICATION AND ACKNOWLEDGEMENT State of Minnesota County of ) ) SS )

The above-named Petitioner/Parent, [parent's name] , being first duly sworn on oath states that Petitioner has read the foregoing Stepparent Affidavit Checklist subscribed by him/her, that Petitioner knows the contents thereof, and that the same is true to Petitioner's best information and belief.
[parent's name]

Petitioner / Parent
[signature] (sign only in front of notary public)

Subscribed and sworn to before me this ___ day of _________________, _____ ________________________________ Notary Public

State of Minnesota County of

) ) SS )

The above-named Petitioner/Parent, [stepparent's name] , being first duly sworn on oath states that Petitioner has read the foregoing Stepparent Affidavit Checklist subscribed by him/her, that Petitioner knows the contents thereof, and that the same is true to Petitioner's best information and belief.
[stepparent's name]

Petitioner / Parent
[signature] (sign only in front of notary public)

Subscribed and sworn to before me this ___ day of _________________, _____ ________________________________ Notary Public

ADO210

State

ENG

Rev 5/08

www.mncourts.gov/forms

Page 4 of 4