Dossier Documents
Nightlight Christian Adoptions
Hong Kong
Adoption Program
Dossier Composition and the Matching Process
For more information on Nightlight’s International Adoption Programs,
contact us by phone or online:
859.263.9964
Nightlight Christian Adoptions provides nationwide adoption services.
Nightlight has offices in:
Anaheim Hills, California
Loveland, Colorado
Lexington, Kentucky
Greenville, South Carolina
© 2012
Mission Statement
To share God’s love through adoption, birthparents’ services and orphan care.
As a Christ-centered adoption agency, believing that every child deserves a loving family, Nightlight Christian Adoptions exists to:
• Promote permanency for children by facilitating international and domestic adoptions and adoption related social services
• Minister to birthparents by providing free, non-directive counseling
• Minister to orphaned and street children by providing humanitarian aid and sharing the Gospel of Jesus Christ through its outreach projects
• Prepare families to successfully parent adopted children
Contents
Introduction 5
Quick Overview of Requirements 5
The homestudy 5
Nightlight’s responsibilities 6
Responsibilities of the Adoptive Parents 6
Overview of the Homestudy Report 7
Citizenship and Immigration Approval 8
Filling out the I-800A form 8
Mailing the I-800A Form to the “Lockbox” 9
Obtain fingerprinting at the CIS office for your state 9
Complete Your homestudy, described above 10
Approval NOTICE (I-800A approval) 10
Follow-up to Approval Notice 11
Preparing The Dossier & Sending it to Nightlight Christian Adoption 11
Submit to Nightlight the “No Healthy Child Letter” 11
Ensuring that Dossier Documents are Genuine 12
Certification 12
Notarization 12
Preparing Your Hong Kong Dossier 13
Valid driver’s license 13
Passport 13
Vital Records 13
Certificates of Profession / Unemployment / Retirement 16
Monthly Financial Statement (form provided) 18
Diplomas for the highest education qualification 18
Tax Returns 18
General Physical Examination for Adoption Applicant (form provided) 18
Medical Statement (form Provided) 19
References 19
Child Preference Form (form provided) 19
Police Clearances 19
Guardianship Statement 20
Family Photos 20
Po Leung Kuk Intercountry Adoption Application Form 20
Statement of Acceptance of Adoption 20
Assumption of Responsibility Pending Adoption Completion 21
The Matching Process 21
Presentation of a Child 21
Deciding whether to accept a referral 22
Provisional Approval 22
Contact with your child 22
Checking Your Paperwork 23
Special Needs Parent Education 23
Travel 23
Insurance for Your Adopted Child 24
Ensure that Documents are Up-to-Date 24
Educating Yourself 25
Immunizations for Hong Kong Travel 25
Preparing your friends for the arrival of your child 26
Travel to Hong Kong 26
Wrapping Up 27
DOSSIER AUTHENTICATION CHECKLIST 29
Introduction
Thank you for selecting Nightlight Christian Adoption’s Hong Kong program. You are now on your way to bringing into your home a child who needs a family. The more quickly you can put together your paperwork and send it to us, the faster the overall process should be. This is the one area where you can make a difference in the timeframe of your overall adoption. Of course, there are factors outside everyone’s control, including the time that it takes the U.S. authorities and the authorities in Hong Kong to approve paperwork. Waiting for the various government approvals is difficult for many of our clients.
In this outline, we will also discuss how you can be matched with a child, and what it will be like while you are waiting for your child to join your family.
Quick Overview of Requirements
For every international adoption, the following basic steps must be taken:
✓ Complete your homestudy and receive approval
✓ Complete your dossier (a collection of documents that represent you)
✓ Receive Adoption Approval document (I-800A) from the United States Citizenship and Immigration Approval/National Benefits Center (USCIS/NBC)
✓ Secure notary certification from County Clerk (check to see if your state requires county certification)
✓ Receive approval from the Hong Kong Social Welfare Department
✓ Submit the form I-800 to the NBC in the U.S. along with certain other documents
✓ Receive approval from the NBC and also the National Visa Center in the U.S.
The homestudy
Note: If you are outside of Kentucky, South Carolina, Southern California, or Colorado, please contact us before you select a home study agency. We have a state-by-state list of recommended home study agencies. Also, your homestudy agency must complete the written interagency agreement supplied by Nightlight Christian Adoptions. Please confirm with your homestudy agency that they have this agreement in place; if not, have them contact AHH before beginning your home study. Once you are doing a homestudy with a cooperative homestudy adoption agency in another state, your homestudy must meet Hague[1] requirements and Nightlight must review the homestudy before it is finalized.
One of the functions of your homestudy is to determine which types of special needs you will be able to care for in your family. Therefore your homestudy must be very specific regarding the type of special needs child you are approved to adopt. The U.S. Consulate that issues your child’s visa in Hong Kong relies on your homestudy for this information. Therefore, your homestudy should have two sections regarding the type of child you are seeking to adopt: (1) Your preferences regarding age, sex, and the special needs of the child, and (2) A list of all the special needs and age range of the child for whom you are approved to adopt. Sometimes a family may be willing to adopt a child with one of a number of different special needs if, for example, this will reduce the amount of time that they will wait for a child to become available.
For example, if you prefer to adopt a boy under two years old with a cleft palate/cleft lip, your homestudy provider will indicate this in the Child Desired section of the homestudy. With your agreement, in the Recommendation section, the homestudy provider will most likely approve you for a boy and a girl, a slightly older child, and one who may have more conditions in addition to a cleft palate/cleft lip, including certain treatable communicable diseases. This Recommendation section may indicate, for instance, that you are approved to adopt a child of either sex up to 36 months old with a cleft lip and/or palate or bi-lateral cleft lip, as well as developmental delays, and communicable diseases, including TB and hepatitis B. Again, this flexibility in your willingness to accept more than one type of child may shorten the length of time that you will wait for a child. However, you make the final decision about what should be placed in the Recommendation section.
Nightlight’s responsibilities
1. Nightlight agrees to give the homestudy agency a checklist of requirements for the homestudy and the post-adoption reports so that these will comply with Hong Kong and USCIS regulations.
2. Nightlight agrees to provide the homestudy agency with a cooperative agreement.
3. Nightlight agrees to review the draft of the homestudy before it is submitted to the NBC. This review ensures that the homestudy complies with U.S. Immigration and Hong Kong requirements, giving additional peace of mind to the client.
Responsibilities of the Adoptive Parents
1. You must ensure that the homestudy is conducted by a licensed, non-profit Hague-accredited adoption agency. (Your home study will not be accepted if it is completed by a non-Hague accredited provider.) Once you have chosen an adoption agency near your home to conduct your homestudy, you must contact Nightlight with their name and contact information. We will then enter into an agreement with your home study agency and provide them with our requirements for the home study.
2. Nightlight must approve the adoption agency that is conducting your homestudy before the homestudy process begins.
3. The Hong Kong Social Welfare Department requires not only the homestudy, but also five reports from you and your homestudy agency after you bring your child home. (These are called post-placement reports). You must agree to these terms if you wish to adopt from Hong Kong.
4. If Nightlight is not your homestudy agency, you must pay your homestudy agency for these five post-placement reports before you receive your child. The agency providing the post-placement reports must hold this money in trust for you for this purpose. If Nightlight is your homestudy agency, your costs for post-placement reports are included in the fee schedule that you have already received.
Overview of the Homestudy Report
1. Description of the date, place, and time of meetings with caseworker
2. A description of your motivation for adoption
3. A description of your family background, relationships, interests and hobbies, and education, and work history
4. Marital status
5. Status of children
6. Health status
7. Family financial status
8. History of abuse, violence, and criminal record
9. Living conditions
10. Plan for parenting
11. Education plans
12. Post-adoption assessment plans
13. Adult children and any other adults living in home
14. Guardianship plans
15. Statement of previous rejection or unfavorable homestudy
16. Duty of candor
17. Ongoing duty to disclose
18. China’s specific requirements for adoptive parents
19. References *See info below regarding References
• Hong Kong requires a minimum of 3 references for your dossier. These reference letters should be originals and should be notarized and sent to Nightlight. It is best that these references are from non-relatives except in the case of an adult child.
• If you have any adult children, one reference must come from one of your adult children.
• Your home study agency will also require references in order to complete your home study. If your home study agency requires original copies, you will need to ask your references to provide you with two original notarized reference letters so that you can provide one copy to your home study provider and one copy to Nightlight for your dossier.
20. Assessment and recommendation
Citizenship and Immigration Approval
The United States Citizenship and Immigration Services (USCIS or CIS) is the agency that gives the United States’ approval for the adoption. Because Hong Kong is a Hague country, the approval comes from a national office called the National Benefits Center (NBC). Approval from CIS/NBC (Immigration) can be divided into three stages:
✓ Filling out your application for U.S. Immigration approval
✓ Being fingerprinted at your local USCIS office
✓ Completing your homestudy
Filling out the I-800A form
This application is also called the “Application for Determination of Suitability to Adopt a Child from a Convention Country”. The form can be downloaded from the USCIS website (at site search I-800a). Instructions are included with the form and are fairly straightforward. Send this form to USCIS/NBC after making a copy for your records.
If you have additional adult household members, you must also complete a form I-800A supplement 1 for each person.
USCIS charges a one-time filing fee of $720, plus $85 for each adult 18 years old or above living in your household. Along with the I-800A form and your check, send photocopies of the following documents (this is included in the instructions for the I-800A):
✓ A birth certificate for each petitioner (husband and wife) as well as for any other adults living in the home (persons 18 years old and above)
✓ Marriage certificate of the petitioners
✓ Divorce decree(s) or death certificate(s) of former/late spouse (if applicable)
✓ Court disposition for any crime (including misdemeanors) that you may have been charged with–even if you were not found guilty or the record has been expunged
✓ For any crimes with which you were charged and/or convicted, a Letter of Remorse signed under Penalty of Perjury must be included listing circumstances surrounding event and any rehabilitation you have received. Please contact Nightlight for more info.
✓ Proof of citizenship for at least one spouse if both were not born in the U.S.
✓ Proof of legal residency if one spouse was not born in the U.S. and the other spouse is a U.S. citizen
Mailing the I-800A Form to the “Lockbox”
The initial I-800A application, along with its fee and supporting documentation are sent by you, the adoptive family, to one of the following “lockbox” addresses:
If sent by regular mail:
USCIS
P.O. Box 660087
Dallas, TX 75266
If sent by Express Mail or courier:
USCIS
ATTN: Hague
2501 S. State Hwy. 121 Business, Suite 400
Lewisville, TX 75067
We highly recommend sending important documents via Express Mail, FedEx or UPS so that you can track them.
Obtain fingerprinting at the CIS office for your state
In most cases, the homestudy and I-800A are submitted to the National Benefits Center lockbox at the same time. Once your check has cleared, the application and accompanying documents are scanned, given a tracking number, and automatically sent to the NBC in Missouri.
In some states your homestudy is sent separately to lockbox (and then to the NBC in Missouri), either by your homestudy agency or by the Department of Social Services.
Once your I-800A (and in most instances your homestudy) is submitted to lockbox, you will receive a letter stating that they have received your application and that you must send in your homestudy within 45 days. If you send in your I-800A application too soon, and your homestudy does not get there within 45 days, you may be required to pay the Immigration application fee again.
Once you have submitted the application and above documents, the National Benefits Center will notify you of an appointment to be fingerprinted at your local USCIS office. Both petitioners, along with any other adults living in the home, must be fingerprinted. The purpose of fingerprinting is for USCIS to check your criminal history with the FBI fingerprint registry.
The results of these fingerprint scans go through the FBI and are processed and transmitted almost immediately to the NBC. Neither you nor your agency can see the results of these criminal clearances.
Complete Your homestudy, described above
The third (and most substantial) component necessary for gaining USCIS/NBC approval is full completion of your homestudy. As just described, the homestudy is sent to lockbox with your I-800A.
Approval NOTICE (I-800A approval)
Approximately 45 days after the NBC has received both your homestudy and your criminal clearances from the FBI fingerprint registry, you should receive your Approval Notice, also referred to as an I-800A approval. A copy of this form will become part of your dossier.
The approval expiration date is printed on the Approval Notice. You want to make sure that your I-800A is valid at the time you travel to Hong Kong to adopt your child. The form I-800, Petition to Classify Convention Adoptee as an Immediate Relative, must be submitted on behalf of the specific child, or children, you intend to adopt BEFORE the expiration date of your I-800A approval notice.
The period of approval of your Form I-800A is based on the validity of fingerprint clearance records. USCIS fingerprints are valid for 15 months. Your I-800A approval and fingerprint record clearance for you, your spouse and any adult member(s) of your household must remain valid until the U.S. Department of State provides visa issuance for your adopted child.
IT IS UP TO YOU TO KNOW WHEN YOUR ADOPTION APPROVAL WILL EXPIRE.
You may request one free extension of the approval period of Form I-800A no sooner than ninety (90) days prior to expiration by submitting the Form I-800A, Supplement 3, Request for Action on Approved Form I-800A prior to the expiration of your approval notice.
To request your one time free extension:
1. Submit Form I-800A, Supplement 3, Request for Action on Approved Form I-800A. This request for extension should be submitted to the lockbox facility where you sent your initial I-800A application.
2. Fingerprinting. NBC will schedule an appointment for you to be re-fingerprinted at your local USCIS office. This biometrics appointment will be free of charge.
3. Updated Homestudy. Your homestudy will need to be updated, even if there are no changes in your circumstances. Your social worker must meet with you to update the homestudy. This will include individual meetings with each spouse and must take place in your home. All criminal and child abuse clearances for the state in which you reside must be obtained again, as well as documents verifying your current medical and financial status, letters of reference, etc.
Once NBC sends this second Approval Notice, it is current for another 15 months from the date of the Fingerprint clearance date. Only one free extension will be granted. In the unlikely event that you have to file another I-800A (not just an extension of the original), you will have to pay the full Immigration fee for re-filing. Most adoptions of special needs children take place well within 30 months.
Follow-up to Approval Notice
After you receive your Letter of Acceptance (LOA) from Hong Kong approving your adoption of a specific child, you will need to file Form I-800, Petition to Classify Convention Adoptee as an Immediate Relative. Visas 37 Cable of Approval. When you received your Approval Notice (I-800A Approval) from NBC, NBC sent a cable to the National Visa Center in New Hampshire, which then sent a cable to the U.S. Consulate in Hong Kong.
Preparing The Dossier & Sending it to NightLIGHT
Your dossier (pronounced DOSS-ee-ay) is the collection of paperwork and documents which will represent you to several U.S. government offices and to the Hong Kong Social Welfare Department. But before further discussion of the dossier ...
Submit to Nightlight the “no Healthy Child Letter”
An important issue in international adoptions is that all children, regardless of age, have some medical, emotional and/or developmental problems. There are no “healthy” children available for international adoption, even though the degree of health risks and special needs will vary greatly. It is important that you understand the risks involved and we ask that you submit the “No Healthy Child Letter” to our office before beginning your dossier. This document was sent to you when your application to adopt was approved by Nightlight.
Ensuring that Dossier Documents are Genuine
The first step in preparing the dossier documents is to prove that they are genuine. The genuineness of your documents can be proven by:
✓ Certification
✓ Notarization
Please make sure that the notary you are using has a commission that expires more than 12 months from the date she is signing the document. Adoptions can take up to one year, and if the notary commission expires within the year you adopt, you may be required to redo dossier documents. In general, to keep all of the paperwork together and to streamline the process, we recommend sending all documentation to Nightlight at one time so that we can review your dossier in its entirety.
Nightlight Christian Adoptions provides dossier consulting and preparation for all our clients. This assistance ensures consistency in dossier preparation. It also streamlines the process and reduces the amount of time you have to spend on paperwork.
The following is a more detailed explanation of how the documents are processed:
Certification
Vital records (birth certificates, death certificates, marriage certificates, and divorce decrees) do not require a notary public’s signature. Rather, they need to be certified copies. Certified copies are the equivalent of notarized ones. Vital records come certified from your Vital Records Department when you request that they be certified copies. Therefore, for example, when you order your birth certificate, request “a certified birth certificate.”
Notarization
Notarization is the process whereby a notary public witnesses the signing of a document. All dossier documents must be notarized, with the exception of vital records (your birth certificate, marriage certificate, death certificate [if needed], and divorce decree [if needed]). Each state has its own requirements for the wording used by its notary publics. We can give you the correct wording for your state—some are more particular than others.
The documents that we print and provide for you incorporate the most complete wording required, with the intent that the documents will be acceptable by the Hong Kong authorities.
Generally you must present to the notary your driver’s license, i.d. card, or passport. It must be current, have your photograph, personal description, and signature, along with a serial or other identifying number. Check with your notary public beforehand to make sure that you bring the proper identification with you.
In cases where a notary public is unavailable, (for example, in your doctor’s office), you may want to contact your local Secretary of State for a list of notaries who could accompany you to your appointment.
Once your documents are notarized, you can send your dossier documents to Nightlight for final review.
Preparing Your Hong Kong Dossier
After your documents are notarized and approved by Nightlight, the final Dossier will be sent to the Hong Kong Social Welfare Department. This dossier represents your family in Hong Kong, and we at Nightlight strive to make sure that it will represent you accurately and successfully. We will review your dossier several times before sending it to Hong Kong.
The documents listed below are for your Dossier. This list corresponds to your “Dossier Document Checklist,” provided by Nightlight Christian Adoptions.
Valid driver’s license
Both adoptive applicants must submit a legible copy of their valid driver’s licenses. Upon making a copy, you will need to attach a statement which says, “I hereby certify that the attached photocopy of my driver’s license is a true, accurate, authentic and unaltered copy of the original license issued by the {state where your license was issued} department of motor vehicles.”
You must then sign and have this statement notarized and attached for each copy of the driver’s license.
Passport
Both adoptive applicants must submit a legible copy of the data page of their passport. Upon making a copy, you will need to attach a statement which says, “I hereby certify that the attached photocopy of my passport is a true, accurate, authentic and unaltered copy of the original issued by the US State Department.”
You must then sign and have this statement notarized and attached for each copy of the passport.
Vital Records
Vital records are certified documents (so no need for notarization). When Nightlight submits your vital records to the Chinese Embassy in D.C., the records must have been issued within the last six months. Your vital records are your birth certificates, marriage certificate, divorce decree (if needed), and death certificate (if needed). If you have adopted other children, Hong Kong also wants to see those adoption decrees. Here are the details:
1. Birth Certificates
• Each member of the household must provide a newly issued certified copy of his or her birth certificate. This must be your full birth certificate (not a small card you carry in your wallet). Order this form from the Vital Statistics office of the state in which you were born.
• It should include your name, sex, date of birth, place of birth, and parents’ names.
• The birth certificates are not notarized. Make sure that they have the appropriate signature from the current State Registrar and a seal from Vital Records, and then send them to our office.
• If you were not born in the U.S., follow the instructions on the next page:
|the information on this page is Only for those |
|who are not a U.S. citizen or were not born in the U.S. |
|If you are not a United States citizen: |
|Make a photocopy of your foreign birth record. |
|Attach a separate sheet of paper to the photocopy with the following statement: |
|I, [your name], verify that the attached birth certificate issued by __(country)__ is an accurate photocopy of an original |
|document. |
|Sign your name in the presence of a notary public, and obtain his notarization. The notarization must then be authenticated [how |
|and by whom?]. |
|If you were not born a United States citizen and you are a naturalized U.S. citizen: |
|Make a photocopy of the date and signature page of your United States passport. |
|Attach a separate sheet of paper to the photocopy with the following statement (on a document with the appropriate notary public |
|language at the bottom): |
|I, [your name], verify that the attached passport page issued by ___(country)___ is an accurate photocopy of an original document. |
|Place your naturalization number (from your naturalization certificate) into the following statement (on a document with the |
|appropriate notary public language at the bottom): |
|I, [your name], verify that my naturalization number is ___________. |
|Sign your name in the presence of a notary, and obtain his notarization. The notarization must then be sent to Nightlight to be |
|authenticated. |
|If you were born abroad to a United States citizen and your birth was registered with the United States upon return: |
|You may obtain a Certification of Report of Birth Abroad from the State Department. Instructions can be found at travel.. |
|Search “Documentation of U.S. Citizens Born Abroad”. |
|The fee for express return delivery is now $16.25, in addition to the $50 fee for the two Certifications of Report of Birth Abroad.|
|Sometimes information not on the website is given at the beginning of the voicemail recording for the State Department office that |
|handles these documents: (202) 955-0307. |
|This recording also gives you the same information as the website, but is much more complicated than obtaining the information |
|online. |
|On the phone, listen to the recorded message, then choose the option to “obtain, correct, or amend a Consular Report of Birth |
|Abroad” (phone option #2 as of April 2010). Write down the instructions from the recorded message. |
|Request in writing two certified copies of your Certification of Report of Birth Abroad (DS-1350). |
|As of April 2010, your request must (1) be notarized and (2) include a copy of your valid driver’s license or another valid |
|identification. The first copy of the Certification of Report of Birth Abroad costs $30, and each subsequent copy costs $20. Send |
|payment by check or money order payable to the “Department of State.” |
1. Marriage Certificate/Divorce Decree
• If you have a previous marriage, you will need to provide a copy of the divorce decree or death certificate related to that marriage
• If your current marriage took place in the United States, request a certified copy of your current marriage certificate. Order this either from the Bureau of Vital Statistics or from the records office in the county where you were married. Again, we can tell you how to order these forms.
• If your current marriage took place in a foreign country:
o make a photocopy of your foreign marriage certificate. Have the marriage certificate translated into English. Attach a separate sheet of paper to the photocopy with the following statement:
We, [Jane and John Doe], verify that the attached marriage certificate issued by __(country)__ is an accurate photocopy of an original document.
o Sign your names in the presence of a notary public, and obtain his notarization.
Certificates of Profession / Unemployment / Retirement
Each of you must submit an individual certificate.
If you are employed by a company, the employer must prepare a letter on your behalf that includes all of the following:
• The employer’s letterhead, the date of letter composition, and signature of employer
• Your profession
• Your position
• Your length of time employed
• Your annual salary[2]
• The probability of continued employment
• If your employer is not willing to make a statement regarding continued employment, ask him to state in the letter that “it is against this company’s policy to make any projections regarding continued employment.”
This document must be notarized.
If you are self-employed, then the certificate must be submitted by a certified public accountant on his letterhead. It must include all elements listed above. If you are an accountant, then the statement must be submitted by a CPA other than yourself. The self-employment letter from the CPA must be notarized.
If you are unemployed:
1. If you are a full-time homemaker or student and not contributing to the family income, you must submit a Certificate of Unemployment, which includes the following:
• The title: Certificate of Unemployment
• The date of composition
• The statement:
I, [Jane Doe], residing at [111 Parker Lane, Greenville, South Carolina 29615], verify that I am not employed (for example, full-time homemaker or student) and therefore do not contribute to my family income through employment outside of our home.
• The financial resources that allow you to stay at home
• Whether you have any plans for future employment
This certificate must be notarized.
2. If you are retired, then you must submit a Certificate of Retirement issued by an accountant or CPA. This certificate must include the following:
• Time of retirement
• Annual income before retirement
• A statement of whether you receive any income after retirement and if so, the amount of that income
This certificate must be notarized and authenticated.
Note: Please give your homestudy provider a copy of all employment letters, since the employment information listed in the homestudy must be identical with the information stated in employment letters.
Monthly Financial Statement (form provided)
Complete this statement by using the form that we send you. The annual income of the adoption applicants must be identical to the income listed in the employment/retirement letter(s) and homestudy.
This document must be notarized.
Note: Please give your homestudy provider a copy of this financial statement, as the financial information listed in the homestudy must be identical with the information stated on this form.
Diplomas for the highest education qualification
Both adoptive applicants must submit a legible copy of their highest diploma received. Upon making a copy, you will need to attach a statement which says, “I hereby certify that the attached photocopy of my diploma is a true, accurate, authentic and unaltered copy of the original issued by the {issuer}.”
You must then sign and have this statement notarized and attached for each copy of the diplomas.
Tax Returns
You will need to submit a copy of your most recent tax return. It is not necessary to submit the full report but only the front page of your 1040 statement. If you have not yet filed your taxes for the previous year, when completing your dossier, please contact Nightlight for instructions. Please note whether your previous year tax return reflects the same income information provided in your home study, your monthly financial statement form, and your employment letter. If there are inconsistencies, these will need to be explained thoroughly by your home study social worker in your home study. Attach a statement to your tax return that says, “I hereby certify that the attached photocopy of my 1040 tax return is a true, accurate, authentic and unaltered copy of the original.”
This statement will need to be signed by both adoptive applicants and notarized.
General Physical Examination for Adoption Applicant (form provided)
Each adult adoptive applicant (prospective adoptive mother and father)must submit a completed Medical Report form. It must be neatly written; if the handwriting is illegible, the form will be considered null and void. It must be completed in Black ink pen in Block letters. This medical report cannot be more than 12 months old when submitted to the Hong Kong authorities. Pay specific attention to the following:
1. The physician must complete all the questions. There should be no blanks. If the question does not apply to your family, he should write in “not applicable” but DO NOT leave the line blank.
2. The Medical Report form must be notarized. Note: Please give your homestudy provider a copy of this physical examination report; the health information listed in the homestudy must be identical to the information stated in this physical examination report.
Medical Statement (form Provided)
The medical statement is to be completed on all other family members including children living in the home. This form must also be notarized. This medical statement cannot be more than 12 months old when submitted to the Hong Kong authorities.
references
As stated previously, you will need to provide 3 letters of reference. These letters should be originals, signed and notarized by the person writing the letter.
• Hong Kong requires a minimum of 3 references for your dossier. These reference letters should be originals and should be notarized and sent to Nightlight. It is best that these references are from non-relatives except in the case of an adult child.
• If you have any adult children, one reference must come from one of your adult children.
• Be sure to select references who have known both you and your spouse for more than 1 year (the longer they have known you the better).
• Please have them address the nature of your relationship with the reference person, their observance of your skills as a parent, and whether or not they would recommend you to adopt a child.
• Your home study agency will also require references in order to complete your home study. If your home study agency requires original copies, you will need to ask your references to provide you with two original notarized reference letters so that you can provide one copy to your home study provider and one copy to Nightlight for your dossier.
Child Preference Form (Form Provided)
This form is required for all applicants regardless of whether or not you have pre-identified a child you are interested in adopting. Please have this form notarized as well.
Police Clearances
Each adult (age 18 or older) living in the adoptive family’s household must submit a certificate issued by a police authority - city, county, state, or FBI are all acceptable. You may not combine two applicants’ record checks on one sheet of paper; they must be separate.
If you obtain a letter from your local police department, it should state the following:
A local criminal history check of all available records has been conducted by the “X” Police Department on the following individual: [Jane Doe]. It has been determined that the aforementioned individual has no criminal record in the city of “X.”
This report will be considered valid for 6 months after the date of issuance.
The certificate should be dated, signed, and notarized before a valid notary public of the office.
Guardianship Statement
This form is to be completed by you to let Hong Kong know that you have chosen guardians for your child if anything were to happen to you and your spouse. Please be sure to include this form in your dossier documents and have it notarized.
family photos
1. Submit photos reflecting your family life. These photos should include the following: one of the adoptive couple; one of each parent individually; one of your children (together or separately); one of your family together and one of the front of your home. Please ensure that none of the photos include bathing suits, revealing clothing, kissing, alcoholic beverages, or pets. Include simple captions under each photo (Example – “Mom-Jane; Dad-John; Parents-John & Jane; Your Sisters; Our Home, etc). (These do not have to be notarized.)
Po Leung Kuk Intercountry Adoption Application Form
This form must be completed in its entirety and submitted with your dossier (or prior to if you have pre-identified a child and would like to receive provisional approval). The financial section of this form must be completed in Hong Kong Dollars. In order to “convert American Dollars to Hong Kong Dollars” you can put this statement in the search bar on your computer and should be able to find a simple conversion calculator.
Please be sure to submit the original which has been signed by you and your spouse and notarized.
Statement of acceptance of adoption
If you have received pre-approval from Hong Kong to be matched with a specific child, this form must be submitted with your dossier. This form needs to be signed by both parents and notarized. This form must be on Nightlight letterhead. If you have not received this form with your child’s information completed and on Nightlight letterhead, please contact our office.
Assumption of Responsibility Pending Adoption Completion
This form must be completed by Nightlight Staff who will send to Hong Kong with your other dossier documents once they are received.
The Matching Process
Children from 1 year to 15 years of age with special placement needs are available for adoption. Special placement needs may include medical health needs, mental health needs, or birth family issues. Some waiting children have moderate to severe special needs such as Thalassemia or Down syndrome, and some older children are available who have no apparent medical problems. It is possible for a family to pre-identify a child that Nightlight is trying to find a family for and then submit a few documents to Po Leung Kuk for “provisional approval” from Po Leung Kuk. Once a family receives their “provisional approval”, they have 3 months to complete the home study and dossier to be submitted to Hong Kong.
Another option is to apply to the Hong Kong program and submit the home study and dossier to Po Leung Kuk. Po Leung Kuk will review the waiting children in the Hong Kong Social Welfare Department and make a referral to the family from that list.
In either case, a family is not considered officially matched until they have submitted their entire dossier and home study to the Hong Kong Social Welfare Department, received the child’s official referral, and submitted their “Statement of Acceptance for Adoption” to Hong Kong.
Presentation of a Child
Nightlight Christian Adoptions will present a child to you when a child who matches your criteria becomes available. This is called a referral.
If you are interested in a child with minor or correctable health issues, most likely your wait to be matched will be longer. The length of your wait for the referral of a child also depends on the age and sex of the child you have requested. In general, the wait for a girl is longer than for a boy. Typically, families can receive a referral within 1 to 3 months; however this is dependent upon many factors including the family’s preferences and the children made available.
When a child is presented to you, you will be given pictures of the child, a medical report and a developmental report. Some children will have more pictures and medical/developmental information than others. The reports will also include social history, psychological history, developmental history, immunization records, and more.
Deciding whether to accept a referral
If you decide that the child assigned to you is not an appropriate match, you may decline the referral. The authorities in Hong Kong will begin to look for another child that meets your criteria. However, we want to be sure that a family does not sign up for the special needs program when, in fact, they want a healthy child as all children adopted internationally will have possible health issues, developmental issues, and environmental neglect. It is important for you to be very clear ahead of time which special needs or medical situations are appropriate for your family.
Because Nightlight desires to find homes for waiting children, each family when presented with a referral will have up to two weeks to make a decision regarding that child. After two weeks, if the family has not yet decided this will need to be discussed individually with your case manager as we do not want to unnecessarily hold a child for a family who will ultimately decline the referral when there may be another family ready to accept that child.
During this two week period, we strongly recommend that you have the child’s entire file reviewed by a doctor who specializes in international adoption. For a list of possible international adoption clinics in your area, please contact our office.
If you decide to accept your referral, you will sign the “Statement of Acceptance for Adoption” and return it to Nightlight. We will then forward this statement along with other documents to the Social Welfare Department of Hong Kong
Provisional Approval
As mentioned earlier, it is possible for a family to receive “provisional approval” from Po Leung Kuk to be matched with a waiting child prior to having submitted your full dossier and home study to the Hong Kong authorities. This is done by submitted the full Po Leung Kuk application and in some cases additional documents will be required. Upon receiving the official provisional approval from the Po Leung Kuk, families will have 3 months to complete their dossier and home study and submitted it to the Hong Kong Social Welfare Department for an official approval and referral of the child.
Contact with your child
Once you have been officially matched with a child in Hong Kong (dossier and home study are approved and you have submitted the “Statement of Acceptance for Adoption”, it may be possible to send care packages to your child. In some cases, with older children, Po Leung Kuk will also arrange skype phone calls with your child prior to travel. We will provide instructions regarding care packages at a later time.
Checking Your Paperwork
Immediately after accepting a referral, you should check over the following paperwork.
1. The Home Study: You need to be sure that the child referred to you is within the age range specified in the home study recommendation and will remain in that age range when you arrive in the United States with your child. If the result is outside the age range for which you were recommended and approved, you need to request a home study update from your social worker.
2. USCIS I-800A Approval: Double check your I-800A approval to make sure that the child fits within the approval given and that the Expiration Date will not expire before you travel to Hong Kong and arrive back home. In order to update the USCIS approval you will need to file Form I-800A, Supplement 3.
3. Fingerprint Expiration Date: This date is also printed on your I-800A Approval. Please make sure that the fingerprint approval will not expire before you travel to Hong Kong and return back to the United States.
Special Needs Parent Education
Once you are matched with a child, you will receive Special Needs Parent Education Requirements that are specific to your child’s special needs.
You will need to speak to a physician to discuss the child’s file and demonstrate your understanding of your child’s special need and how it may manifest in worst and best case scenarios. You need to demonstrate that you are well educated regarding the needs of the child you are planning to adopt. This includes the medical issues, prognosis, and treatment of your child’s special needs.
It is also important that you understand attachment issues, the child’s adjustment to a new language, new food, new sounds, and many other new things. You should demonstrate your understanding of the changes that you will encounter, changes that will occur between you and your spouse (if applicable), and changes with your other children (if any).
Therefore, you must complete the Special Needs Parent Educationa statement indicating that you have been further educated beyond the education that you completed for your homestudy report
TRAVEL
Once you have submitted the Statement of Acceptance of Adoption, Hong Kong will process the adoption in the Hong Kong courts. Upon approval from the courts, you will begin the I-800 process by which the NBC must approve your adoption of the specific child you have been matched with. Nightlight will navigate this process for you and let you know when you can make your travel arrangements to travel to meet your child. We will send more detailed I-800 and travel information after you have received your official referral and acceptance.
Insurance for Your Adopted Child
If you have a group medical insurance plan, your provider is required to treat your adopted child like your biological child. Your employer and provider may not be aware of this, so begin talking with them about it now. To qualify your child for coverage, you do not have to file for re-adoption or do any additional paperwork after returning to the States; you can apply for coverage as soon as you assume financial responsibility for the child.
If you have an individual health plan, then you need to check on your state’s laws relating to coverage of adopted children. Most states require individual health insurance plans to provide benefits similar to the federal requirements for group plans.
Note: if you are covered by a group plan (i.e., covered by your employer), you must apply for coverage for your child within thirty days of returning to the States.
An excellent article entitled “It’s The Law: Health Insurance for Adopted Children” can be found at pdf/health_ins.pdf.
Ensure that documents are up-to-date
Your I-800A Approval expires when your FBI clearances expire—15 months after your fingerprints are taken at the Immigration (CIS) office.
If you think that your Immigration I-800A Adoption Approval will expire before you travel or while you are travelling, you must immediately contact your homestudy provider and have an updated homestudy submitted to Immigration. You will either be required to file an I-800A Supplement 3 or a new I-800A application and be fingerprinted again. If you are due a free extension, there is no charge for the first updated I-800A extension; however, you will have to pay for homestudy services to your homestudy agency.
If there has been any significant change in your household, including change in finances (decrease), another person living in the home, a change of residence, any criminal or child abuse allegations, change in health status, etc., you must contact Nightlight and your homestudy provider so that your homestudy can be updated and an new I-800A filed. There is a charge with Immigration for this.
Make sure your passports are current for at least 6 more months at the time that you will be traveling. If your passports will be expiring, make arrangements to get new ones.
Educating Yourself
Now that you know your specific child and the special needs that she has, it is important that you clearly understand her condition and find out which medical resources are available in your community and around the country.
Regardless of how young a child you request, most families bring home a child who is at the very youngest one year old. Most families will adopt a toddler or older child. These older children usually have experienced one or more changes in caregivers; they are sometimes neglected, and may have been abused. Some or much of your child’s background will likely be unknown.
It is usually more difficult for an older child to attach to you and to make the many other necessary transitions. Knowing how to meet these kinds of needs can be more ambiguous and more challenging than the effort extended in meeting the child’s physical and medical needs.
It is very easy to focus on your child’s medical or developmental issues, the issues that are, in a sense, the easiest to identify and resolve. However, these children often have psychological and emotional issues due to multiple caregivers, neglect, and possible abuse. The effects of these can extend long after the medical issues are resolved.
We recommend that you continue to educate yourselves on adoption-related issues during this time. The educational requirements that you were to complete before your homestudy was approved are only the beginning of your education. It is very important that you use this time to read and participate in some of the many resources available.
Immunizations for Hong Kong travel
While you are waiting to travel, this is a good time to make sure that you have received all of the immunizations that you need for travel to Hong Kong. Certain diseases such as hepatitis A and B require multiple immunizations over an extended period of time. Also, many adults are not aware that they need to have booster shots against diseases that they were vaccinated against as children. Most adults do not have current immunization against tetanus.
Usually the least expensive way to obtain updated immunizations is at your local health department and your local health department should also recommend to you the immunizations needed and bringing you up-to-date with your booster vaccinations. You may have to make an appointment a few months in advance, so now is the time to contact them. The health department should have the most up-to-date information on the shots you need for traveling to Hong Kong. If immunizations are not available from the county, check with your physician. Because some of the vaccines come in series over several months, don’t delay in initiating the process.
Passport Health, , the largest organization for travel medical needs with clinics all around U.S., provides immunization services. This commercial organization’s staff tend to encourage immunizations against many diseases that you are unlikely to get if you stay in the larger cities in Hong Kong.
Typically, you’ll need the following shots:
• Hepatitis A: Consult your health provider about whether you need this immunization.
• Hepatitis B: Because this vaccine comes in a series of three shots (spread out over several months), you should begin the process immediately.
• Tetanus: If your tetanus vaccinations aren’t up-to-date, you may need another shot.
Talk to your health care provider about medication to prevent Typhoid if traveling to an area where Typhoid is a problem.
To find the latest information on recommended immunizations, consult the U.S. government’s Centers for Disease Control and Prevention (CDC) on their website: Find “Traveler’s Health Topics” on the left, then click “Destinations.” This site also provides suggestions and precautions for travel to Hong Kong.
Preparing your friends for the arrival of your child
While you are waiting to receive your child, your friends are waiting as well. You have been preparing yourself for a long time for this momentous event, and you have absorbed much more information that you probably realize. Your friends, on the other hand, are most likely not aware of the complexity of adopting a child who has dealt with separation from at least one significant caregiver, and who is from another country.
It is important to help your friends know what to expect when she arrives. Many friends and family members will want to welcome her, hold her, and babysit for you while you “get away for a while.” This is not the best for child in the first 4-6 weeks after she arrives home with you.
Many friends will feel less excluded and will be more able to accept this if they are able to help in some way. It is best to communicate this to your family, friends, community and church before your child arrives home so that they will understand and know what they can do to help.
Travel to Hong Kong
When you accept a referral of a child, we will send you the travel packet to help you prepare.
Before you travel, the Hong Kong courts will process a guardianship order for your child. They will also process your child’s birth certificate/passport, and US visa. When you travel to Hong Kong, you will have no official meetings to attend but can spend the 7 days bonding with your child. When you return to the US with your child, you will finalize the adoption. It is expected that both parents will travel to Hong Kong.
Wrapping Up
The information in this packet is a great deal to absorb. Perhaps completing your tax form is the only task more complicated than learning all of this information. If you feel overwhelmed, please talk with us. We can walk you through the process and advise you on the best way to proceed.
Nightlight Christian Adoptions places a strong emphasis on education, not just before you adopt, but during and afterward. It is a lifelong learning lesson. But do not feel that you need to become a medical expert on every possible condition that a child could have. You need to have a realistic expectation of the conditions that the child may have. It is easy to become more focused on the special needs of the child than on his overall health and well-being and the progress that he can and will make once he is home with you.
Finally, during this time, you should be putting into place good support systems for your family. Take good care of yourself and your family during this time. It can and will be stressful. God most likely has many things to teach you during this time—beyond just patience. You can use this time to carefully consider all the ways that God wants you to grow.
FORMS
HONG KONG DOSSIER AUTHENTICATION CHECKLIST
|Document |Notarization |
|Driver’s License | Husband |
| | |
| |Wife |
|Passport | Husband |
| | |
| |Wife |
|Marriage Certificate | |
|Divorce Decree/Death Certificate | Husband |
| | |
| |Wife |
|Birth Certificate | Husband |
| | |
| |Wife |
| | |
| |All Children |
|Adoption Decree | |
| |All Children |
|Employment/Income Statement | Husband |
| | |
| |Wife |
|Monthly Financial Statement | |
|Highest Diploma Received | Husband |
| | |
| |Wife |
|1040 Tax Return | |
|Medical Report Form | Husband |
| | |
| |Wife |
|Medical Statement | All others in the |
| |household |
|References (plus adult child if applicable) | |
|Guardianship Statement | |
|Family Photos | |
|Child Preference Form | |
|Criminal Clearance | Husband |
| | |
| |Wife |
|Po Leung Kuk Application | |
|Home Study | |
|USCIS Approval Copy | |
|Statement of Acceptance of Adoption | |
|Assumption of Responsibility Pending Completion of Adoption-Completed by | |
|Nightlight | |
Outline Sample
LETTER OF EMPLOYMENT VERIFICATION
COMPANY NAME
COMPANY ADDRESS
CITY, STATE ZIP
(999) 999.9999
(999) 999.9999 - FAX
Date
APPLICANT NAME:
JOB TITLE:
ANNUAL SALARY:
HIRE DATE:
CONTINUOUS SERVICE:
JOB DESCRIPTION:
JOB STATUS/PROSPECT FOR CONTINUOS EMPLOYMENT:
SIGNATURE OF AUTHORIZED COMPANY OFFICIAL
TITLE
Subscribed and sworn to before me by ______________, this ______ of _________, _______.
____________________________
NOTARY PUBLIC
_____________ STATE AT LARGE
My commission expires:________________________
Sample
Statement of Marketplace Unemployment
Date
I, ________________, am not employed outside of the home at this time. My spouse’s income, of $___________, is more than sufficient to meet our family’s financial needs. I was previously employed outside of the home as a _______________ for ____ years. (State any degrees or certificates you hold.)
If it ever becomes necessary for me to work outside of the home, I will be more than able to do so. However, at this time I desire to be a full time, stay-at-home-parent.
___________________________________
Signature
Subscribed and sworn to before me by ___________, this ____day of _______, _______.
____________________________
NOTARY PUBLIC
___________ STATE AT LARGE
My commission expires: ________________________
Po Leung Kuk Intercountry Adoption
|Notes for Furnishing Medical Report |
|The aim of this Medical Report is to establish whether the applicant is physically and mentally fit to shoulder parental responsibility to |
|cope with the demands of an adopted child, at present and in the future. |
|The information provided by applicant for the report is true, accurate and to the best of his/her knowledge. |
|Photocopy and fax copy of this Medical Report Form will not be accepted. |
|Please return this Medical Report to the applicant in a sealed envelope. |
|This Medical Report should be furnished in BLOCK letters and in BLACK ink/ball pen. |
MEDICAL REPORT ON PROSPECTIVE ADOPTER
Name __________________________ Sex ______ Age/D.O.B. ____________________________
Address_______________________________________________________________________________
How long have you known the applicant professionally? ______________________________________________________________________________________
How many consultation/treatment sessions the applicant has attended in your clinic? ______________________________________________________________________________________
Personal History:
1) Please indicate if there is any history of the following illnesses and comment: Yes No
a) Tuberculosis (including non-pulmonary TB.) _____ _____
Asthma or other allergic disorder _____ _____
Bronchiectasis or chronic bronchitis _____ _____
Other respiratory disorder _____ _____
b) Hypertension, or other cardio-vascular disease _____ _____
c) Any form of rheumatism or locomotor disease _____ _____
d) Neurosis, depression, anxiety state, or mental illness _____ _____
e) Head injury, fits, or other neurological disease _____ _____
f) Genito-urinary disease _____ _____
g) Diabetes or thyroid disorder or other endocrinological disease _____ _____
h) Persistent indigestion, peptic ulcer, other intestinal or liver disease _____ _____
i) Malignancy or suspected malignant disease _____ _____
j) HIV infection _____ _____
k) Previous operations or hospitalization records _____ _____
(Please give date, treatment and prognosis if nay one of the above items is “Yes”.)
______________________________________________________________________________________________________________________________________________________________________
2) Does the applicant use alcohol in excess? If yes, please comment
____________________________________________________________________________________________________________________________________________________________________
3) Does the applicant use any of the following in excess? If yes, please comment
Tobacco __________________________ Narcotics ______________________________
Barbiturates _______________________ Tranquillizers __________________________
Comment: _____________________________________________________________________
4) Has any proposed insurance on the applicant’s life been declined, or accepted on special terms by an insurance company?
____________________________________________________________________________________________________________________________________________________________________
Family History:
Is there a family history of the following?
1) Mental illness _________________________ (2) Epilepsy ________________________________
5) Tuberculosis __________________________ (4) Diabetes ________________________________
6) Allergy _______________________________ (6) Hypertension ____________________________
7) Cancer _______________________________ (8) Blood disease ____________________________
9) Familial degenerative disease such as muscular dystrophy ___________________________________
Please comment: _______________________________________________________________________
______________________________________________________________________________________
Fertility History:
1) Any previous conception? ___________________________________________________________
2) For how long has the couple failed to conceive? _________________________________________
3) If fertility is a problem, is it due to
a) Non-consummation______________________________________________________________
b) Infertility in either partner (Please give date and result of investigation) __________________
____________________________________________________________________________________________________________________________________________________________
c) Is any fertility treatment currently being undergone? (if so, please specify and attach relevant documents/reports)
d) Any other reasons, e.g. psycho-sexual difficulties, fear of further pregnancies etc. ____________________________________________________________________________________________________________________________________________________________
e) Are there other tests and/or procedures which could be pursued?
____________________________________________________________________________________________________________________________________________________________
4) Are there other medical reasons why this couple may wish to adopt?
_________________________________________________________________________________
__________________________________________________________________________________
Current Examination Findings:
1) Height (in cm) _______________________ Weight (in kg) _____________________________
2) Is there any detected abnormality in the following:
a) Cardio-vascular system __________________________________________________________
Blood pressure _________________________________________________________________
b) Respiratory system _____________________________________________________________
Chest X-Ray ________________ Date taken (must be within 6 months): ___________________
c) Urogenital system _____________________________________________________________
Urine examination Albumin _____________ present/absent ____________________________
S.G. __________: Sugar _____________present/absent _______________________________
Other ingredients: ______________________________________________________________
d) Alimentary system: _____________________________________________________________
e) Central nervous system: _________________________________________________________
f) Eyes and vision (including fundi) ___________________________________________________
g) Ears and hearing _______________________________________________________________
h) Skin _________________________________________________________________________
i) Haemopoietic and lymphatic system _______________________________________________
j) Hepatitis B Test ________________________________________________________________
Please comment on the patient’s liver functioning if result of Hep. B test is positive: _________
k) HIV Antibody __________________________________________________________________
3) Does the applicant have normal function of all limbs? ______________________________________
4) Do you consider the applicant in good physical health now? _________________________________
5) Do you consider the applicant in sound mental health? ____________________________________
6) Comment:
1) Does the applicant have any medical condition which is likely to shorten life? If yes, please explain
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2) Are there any disabilities or illnesses which you consider would limit or adversely affect the applicant’s ability to care for an adopted child either now, or at any time in future before the adopted child reaches the age of independence?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
3) Do you recommend the applicant as having suitable physical and mental health to adopt a child?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
4) Is there any additional information not included in the above which you consider pertinent to this report?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
5) Have the contents of this report been shared with the applicant? If no, please comment
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date ___________________________ Signature ______________________________
Name in Block Letters ____________________________
Qualifications ___________________________________
Address _______________________________________
_______________________________________
_______________________________________
_______________________________________
Telephone no. _________________________________
(Put a seal at the end of this medical report)
Po Leung Kuk Intercountry Adoption
Medical Statement
(Note: This statement is intended for those family members, both children and adults living in the home of the prospective adoptive parents.)
Date of examination: __________________________
I ___________________________________________M.D.
have examined ________________________________
and find him/her to be in _______________________ (excellent, good, poor, etc.) health.
In his/her medical history, the following illnesses require medical attention or treatment.
____________________________________________________________________
(This section is applicable for the adults, at or over the age of 18 years.)
He/she is not known to have any of the following:
1) HIV/AIDS
2) Sexually transmitted disease
3) History of substance abuse
4) Mentally or psychological disorder
5) Genetic risks
Or any other medical condition that would, in any way, have a negative impact on a child living in the same residence.
Signed_______________________
The following TB clearance section is to be completed for each child over the age of 1 and all adults living in the household of the prospective adoptive parent.
CRIMINAL RECORD CHECK FORM
This form may be used to request a criminal record check from your state of residence and any other state(s) you have lived in within the past five (5) years. Please know that each state may require you to use their own form and some states require an FBI Criminal Clearance for adoptive parents. Therefore, please contact your local police department for instructions on how to obtain a criminal record check.
SECTION I: TO BE COMPLETED BY ADOPTIVE PARENT
NAME OF APPLICANT: __________________________________________
DATE OF BIRTH: ______/_____/_________
SOCIAL SECURITY NUMBER: _________-_____-________
LOCAL ADDRESS: ____________________________________________________________________
STREET CITY STATE ZIP
PLACE OF BIRTH: ______________________________________
FATHER’S FULL NAME: __________________________________
MOTHER’S FULL NAME: __________________________________
PERMISSION FOR RELEASE OF INFORMATION: I willingly give my permission for the above information to be checked and released:
SIGNATURE OF APPLICANT:____________________________________ DATE:______________
SECTION II: TO BE COMPLETED BY AUTHORIZED PERSONNEL OF POLICE DEPARTMENT
To Whom It May Concern:
The above named subject has been checked by our department.
No criminal record was found.
The criminal record of the above named subject is attached hereto.
SIGNATURE OF AUTHORIZED PERSONNEL: _____________________________________________
TITLE: ________________________ NAME OF DEPARTMENT: _____________________________
DATE:_________________________________
State of _________________
County of ________________
Signed and sworn to before me this _____ day of ____________________, ________.
Signature of Notary Public: _____________________________________
My Commission Expires: _______________________
Sample
GUARDIAN STATEMENT
We, _____________________, date of birth ________________ and ____________________, date of birth ________________ do agree and consent to the guardianship of the child to be adopted by ____________________.
We agree to take care of and raise this child as our own should such a need arise.
__________________________ is employed as a _______________ in CITY, STATE and earns an annual income of $____________.
__________________________ is employed as a _______________ in CITY, STATE and earns an annual income of $____________.
We are in (FAIR / GOOD / EXCELLENT) health with no limitations which would inhibit us from caring for this child. We have ____# children, ages _______________ living ( IN / OUT) of the home.
__________________________________ ___________________________________
Signature Date Signature Date
STATE OF _____________________
COUNTY OF ___________________
Signed and sworn to before me this _____ day of _____________________, ______.
My Commission expires: ___________________
____________________________________
NOTARY PUBLIC
[pic]
CERTIFIED COPY OF AN ORIGINAL DOCUMENT
I hereby certify that the attached photocopy of the USCIS approval is a true, accurate, authentic and unaltered copy of the approval issued by the United States Department of Homeland Security, Citizenship and Immigration Service, on our behalf.
_______________________________
Signature
Printed name: ____________________
Date: __________________
STATE OF ________________
COUNTY OF ______________
Signed and sworn to before me this ____ day of ________________, ______.
My Commission Expires: _____________________
________________________________
NOTARY PUBLIC
-----------------------
[1] The Hague Convention on the Protection of Children and Co-operation in Respect of Inter-Country Adoption (the “Hague Adoption Convention”, or “the Hague” for short) is an international agreement to safeguard intercountry adoptions.
[2] The income shown on this form needs to match the income on the Certificate of Income and Property provided as well as in the homestudy.
-----------------------
Last Tuberculosis test date: _______________________Result: _________________________
Or
Chest X-Ray for Tuberculosis date: _____________________Result: _____________________
TB Test Result Certified by: ____________________
................
................
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