STATE OF CALIFORNIA MADERA SUPERIOR COURT STEP-PARENT ADOPTION / DECLARE MINOR FREE Family Court Services 200 South G Street INVESTIGATION INTAKE / QUESTIONNAIRE Madera, CA, 93637 PH #: 559-416-5560 FAX #: 559-673-8216 CASE # ____________FCS CASE #________COURT DATE: ___________ TYPE OF PETITION: STEP-PARENT ADOPTION ($300) DECLARE MINOR FREE ($300) DUAL STEP-PARENT ADOPTION/DECLARE MINOR FREE ($450) NOTE: INVESTIGATION FEE IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT rev. 10/2013 SECTION 1: PETITIONER’S INFORMATION NAME (Last, First, Middle): RELATIONSHIP TO MAIDEN NAMES YOU ARE KNOWN BY: CHILD: NAME: DATE OF PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # BIRTH: TEL. # E-MAIL ADDRESS: HAS THE NON-CUSTODIAL PARENT BEEN SERVED? Yes No STREET ADDRESS SOCIAL SECURITY # DRIVER’S LICENSE # / STATE: CITY STATE ZIP CODE HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS__________ SECTION 2: NATURAL FATHER’S INFORMATION NAME (Last, First, Middle) DO YOU CONSENT TO THE OTHER NAMES YOU ARE ADOPTION/DECLARE THE MINOR FREE KNOWN BY: PETITION? Yes No DATE OF PLACE OF ATTORNEY NAME / TELEPHONE # / FAX # BIRTH: BIRTH: HOME TEL. # CELL TEL. # E-MAIL ADDRESS: STREET ADDRESS SOCIAL SECURITY # DRIVER’S LICENSE # / STATE: CITY STATE ZIP CODE HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS__________ SECTION 3: NATURAL MOTHER’S INFORMATION: NAME (Last, First, Middle) DO YOU CONSENT TO THE OTHER NAMES YOU ARE ADOPTION/DECLARE THE MINOR FREE KNOWN BY: PETITION? Yes No DATE OF OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # BIRTH: HOME TEL. # CELL TEL. # E-MAIL ADDRESS:
STATE OF CALIFORNIA STEP-PARENT ADOPTION / DECLARE MINOR FREE INVESTIGATION INTAKE / QUESTIONNAIRE MADERA SUPERIOR COURT Family Court Services 200 South G Street Madera, CA, 93637 PH #: 559-416-5560 FAX #: 559-673-8216 CASE # ____________FCS CASE #________COURT DATE: ___________ TYPE OF PETITION: STEP-PARENT ADOPTION ($300) DECLARE MINOR FREE ($300) DUAL STEP-PARENT ADOPTION/DECLARE MINOR FREE ($450) NOTE: INVESTIGATION FEE IS DUE FROM THE PETITIONER ON THE DAY OF THE APPOINTMENT rev. 10/2013 SECTION 1: PETITIONER’S INFORMATION NAME (Last, First, Middle): RELATIONSHIP TO CHILD: MAIDEN NAME: NAMES YOU ARE KNOWN BY: DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # TEL. # E-MAIL ADDRESS: HAS THE NON-CUSTODIAL PARENT BEEN SERVED? Yes No STREET ADDRESS SOCIAL SECURITY # DRIVER’S LICENSE # / STATE: CITY STATE ZIP CODE HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS__________ SECTION 2: NATURAL FATHER’S INFORMATION NAME (Last, First, Middle) DO YOU CONSENT TO THE ADOPTION/DECLARE THE MINOR FREE PETITION? Yes No OTHER NAMES YOU ARE KNOWN BY: DATE OF BIRTH: PLACE OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # HOME TEL. # CELL TEL. # E-MAIL ADDRESS: STREET ADDRESS SOCIAL SECURITY # DRIVER’S LICENSE # / STATE: CITY STATE ZIP CODE HOW LONG AT THIS ADDRESS? YEARS:__________ MONTHS__________ SECTION 3: NATURAL MOTHER’S INFORMATION: NAME (Last, First, Middle) DO YOU CONSENT TO THE ADOPTION/DECLARE THE MINOR FREE PETITION? Yes No OTHER NAMES YOU ARE KNOWN BY: DATE OF BIRTH: OF BIRTH: ATTORNEY NAME / TELEPHONE # / FAX # HOME TEL. # CELL TEL. # E-MAIL ADDRESS:
SPA-DMF%20INTAKE%20-%20QUESTIONNAIRE%20-%20REVISED.docx