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}{\info{\title Adoption Home Study Application}{\author Lisa Moody}{\operator Lisa Moody}
}
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\pard \qc\sl360\slmult1 
{\plain \b\ul\f1\fs32 Adoption Home Study Questionnaire\par
}\pard 
{\plain \b\ul\fs28 \par
}\pard \sl360\slmult1 
{\plain \f1 Family Name:\par
}{\plain \f1  Address:\par
}{\plain \f1 City, State, Zip Code:\par
}{\plain \f1 Home Phone:   (       )  \par
}{\plain \f1 Work Phone:    Husband    (     )\tab \tab \tab \tab Wife   (    )\tab \tab       \par
}{\plain \f1 \par
}{\plain \i\ul\f1 For the Husband}{\plain \f1 :\par
}{\plain \f1 Last, first, middle name: \par
}{\plain \f1 Other names used:\par
}{\plain \f1 Date of birth:                           Place of birth:\par
}{\plain \f1 Social Security Number:\par
}{\plain \f1 Citizenship:                              Length of Florida residency:\par
}{\plain \f1 \par
}{\plain \i\ul\f1 For the Wife:}{\plain \i\f1 \par
}{\plain \f1 Last, first, middle name:\par
}{\plain \f1 Maiden name:\par
}{\plain \f1 Other names used:\par
}{\plain \f1 Date of birth: \tab \tab Place of birth:\par
}{\plain \f1 Social Security Number:\par
}{\plain \f1 Citizenship: \tab \tab \tab Length of Florida residency:\par
}{\plain \f1 \par
}{\plain \ul\f1 If you have children, please provide the following information:\par
}{\plain \f1 Name:\par
}{\plain \f1 Date of birth\par
}{\plain \f1 Adopted or biological:\par
}{\plain \f1 School grade:\par
}{\plain \f1 Personality description:\par
}{\plain \f1 Special interests:\par
}{\plain \f1 How do you think this child will react to an adopted sibling?\par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Date of birth\par
}{\plain \f1 Adopted or biological:\par
}{\plain \f1 School grade:\par
}{\plain \f1 Personality description:\par
}{\plain \f1 Special interests:\par
}{\plain \f1 How do you think this child will react to an adopted sibling?\par
}{\plain \f1 \par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Date of birth\par
}{\plain \f1 Adopted or biological:\par
}{\plain \f1 School grade:\par
}{\plain \f1 Personality description:\par
}{\plain \f1 Special interests:\par
}{\plain \f1 How do you think this child will react to an adopted sibling?\par
}{\plain \f1 \par
}{\plain \b\ul\f1 PERSON ARRANGING/FACILITATING YOUR ADOPTION}{\plain \f1 \par
}{\plain \f1 Name:\par
}{\plain \f1 Address:\par
}{\plain \f1 \par
}{\plain \f1 Phone:  (      )                                          Fax:  (     )           \par
}{\plain \f1 \par
}{\plain \f1 Please indicate the purpose of home study:\par
}{\plain \f1 _____\tab \tab Adopting a newborn who is expected to be born on:\par
}\pard \fi-2160\li2160\sl360\slmult1\tx2160\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 _____\tab Adopting a child born on ________ who is not in my/our 
custody at this time.\par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 _____\tab  \tab Adopting a child already in my/our custody.\par
}\pard \fi-2160\li2160\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain _______\tab \tab  }{\plain \f1 Adopting a child from another country.\par
}\pard \fi-2160\li2160\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \tab \tab \tab What country/countries are you considering:  }{\plain \ul\f1                              
                       ___________________________                }{\plain \f1 \par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 }{\plain \b\ul\f1\fs28 AUTOBIOGRAPHY: FATHER}{\plain \f1\fs28 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Name:\par
}{\plain \f1 Date/place of birth:\par
}{\plain \f1 I am number ____ born of ____ brothers/sisters.\par
}{\plain \f1 Number of sisters: \tab \tab  Number of brothers:\par
}{\plain \f1 \par
}{\plain \ul\f1 Father:\par
}{\plain \f1 Name:\par
}{\plain \f1 Age:\par
}{\plain \f1 Employment (if retired, please provide previous field of employment):\par
}{\plain \f1 Personality traits:\par
}{\plain \f1 \par
}{\plain \ul\f1 Mother:\par
}{\plain \f1 Name:\par
}{\plain \f1 Age:\par
}{\plain \f1 Employment (if retired, please provide previous field of employment):\par
}{\plain \f1 Personality traits:\par
}{\plain \f1 \par
}{\plain \f1 Date of parent\'92s marriage:\par
}{\plain \f1 Did they remain married:\par
}{\plain \f1 If divorced, what was your age when they divorced?\par
}{\plain \f1 Did either parent remarry:\par
}{\plain \f1 If so, what was your relationship like with the step-parent?\par
}{\plain \f1 \par
}{\plain \f1 Describe your relationship with your parents while growing up:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Who was the most significant person in your childhood and why?\par
}{\plain \f1 \par
}{\plain \f1 Which parent do you feel assisted you most in your growing years and why?\par
}{\plain \f1 \par
}{\plain \ul\f1 Siblings:}{\plain \f1 \par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \tab \par
}{\plain \f1 \par
}{\plain \f1 Describe family traditions:\par
}{\plain \f1 \par
}{\plain \f1 What did you like best about growing up in your family?\par
}{\plain \f1 \par
}{\plain \f1 What would you change if you could?\par
}{\plain \f1 \par
}{\plain \f1 Are your parent(s) living?\par
}{\plain \f1 If not, how old were you at the time of their death:\par
}{\plain \f1 Please indicate which parent and the circumstances:\par
}{\plain \f1 \par
}{\plain \f1 Are your sibling(s) living?\par
}{\plain \f1 If not, how old were you at the time of their death:\par
}{\plain \f1 Please indicate which sibling and the circumstances:\par
}{\plain \f1 \par
}{\plain \f1 Describe the impact the death(s) had on you:\par
}{\plain \f1 \par
}{\plain \f1 How did you cope with the loss(es)?\par
}{\plain \f1 \par
}{\plain \f1 If your parent(s) is/ are still living, where do they reside?\par
}{\plain \f1 How often do you see them?\tab \tab \tab \par
}{\plain \f1 How often do you talk with them?\par
}{\plain \f1 \par
}{\plain \f1 What is the biggest disappointment you have had in your life?\par
}{\plain \f1 \par
}{\plain \f1 How did you handle it?\par
}{\plain \f1 \par
}{\plain \f1 What personal achievement are you most proud of?\par
}{\plain \f1 \par
}{\plain \f1 What are your personal goals?\par
}{\plain \f1 \par
}{\plain \f1 What are your career goals?\par
}{\plain \f1 \par
}{\plain \f1 What hobbies/leisure activities do you enjoy?\par
}{\plain \f1 \par
}{\plain \f1 Do you use any of the following?\par
}{\plain \f1 \tab }{\plain \ul\f1 ____\tab }{\plain \f1  alcoholic beverages\tab \tab Frequency:\par
}{\plain \f1 \tab _____ narcotics\tab \tab \tab Frequency:\par
}{\plain \f1 \tab _____ tobacco products\tab \tab Frequency:\par
}{\plain \f1 \tab Comments:\par
}{\plain \f1 \par
}{\plain \f1 Have you ever been arrested?  If so, please explain:\par
}{\plain \f1 \par
}{\plain \f1 Have you ever been affected directly or indirectly by:\par
}{\plain \f1 \tab _____Sexual Abuse\tab \tab _____Incarceration\par
}{\plain \f1 \tab _____Physical Abuse\tab \tab _____Alcoholism\par
}{\plain \f1 \tab _____Mental Abuse\tab \tab _____Therapy/counseling\par
}{\plain \f1 \tab _____Drug Abuse\tab \tab \tab _____Financial problems\par
}{\plain \f1 \tab Comments:\par
}{\plain \f1 \par
}{\plain \f1 Please list your strengths:\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 Please list any areas needing improvement:\par
}{\plain \f1 \par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \b\i\ul\f1 Education\par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 High School attended (city, state) :\par
}{\plain \f1 Graduation date:\par
}{\plain \f1 College:\par
}{\plain \f1 Degree obtained:\par
}{\plain \f1 Year obtained:\par
}{\plain \f1 Vocational School:\par
}{\plain \f1 Area of Specialty:\par
}{\plain \f1 Year of Completion:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
}{\plain \b\i\ul\f1 Employment History}{\plain \i\f1 \par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Current Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment:\par
}{\plain \f1 Location:\par
}{\plain \f1 Annual Income:\par
}{\plain \f1 Monthly net salary:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \tab \tab \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
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{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 ********\tab \tab \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
}{\plain \f1 \par
}{\plain \f1 ********\par
}{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
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{\plain \f1 \par
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{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
}{\plain \b\i\ul\f1 Previous Marriages (if applicable)\par
}{\plain \b\ul\f1 \par
}\pard \tqc\tx4320\tx0\tx0\tx0\tx0\tx0\tx0\tx0\tx0\tx0\tx0\tx0\tx0
{\plain \f1 Name of ex-spouse:\tab                                        \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
}{\plain \f1 Date of Marriage:\par
}{\plain \f1 \par
}{\plain \f1 How did you meet:\par
}{\plain \f1 \par
}{\plain \f1 Reason for divorce:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Date of divorce:\par
}{\plain \f1 \par
}{\plain \f1 How is the current marriage different:\par
}{\plain \f1 \par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 ****************************************************************************\par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \b\ul\f1\fs28 AUTOBIOGRAPHY: MOTHER}{\plain \f1\fs28 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Name:\par
}{\plain \f1 Date/place of birth:\par
}{\plain \f1 I am number ____ born of ____ brothers/sisters.\par
}{\plain \f1 Number of sisters: \tab \tab  Number of brothers:\par
}{\plain \f1 \par
}{\plain \ul\f1 Father:\par
}{\plain \f1 Name:\par
}{\plain \f1 Age:\par
}{\plain \f1 Employment (if retired, please provide previous field of employment):\par
}{\plain \f1 Personality traits:\par
}{\plain \f1 \par
}{\plain \ul\f1 Mother:\par
}{\plain \f1 Name:\par
}{\plain \f1 Age:\par
}{\plain \f1 Employment (if retired, please provide previous field of employment):\par
}{\plain \f1 Personality traits:\par
}{\plain \f1 \par
}{\plain \f1 Date of parent\'92s marriage:\par
}{\plain \f1 Did they remain married:\par
}{\plain \f1 If divorced, what was your age when they divorced?\par
}{\plain \f1 Did either parent remarry:\par
}{\plain \f1 If so, what was your relationship like with the step-parent?\par
}{\plain \f1 \par
}{\plain \f1 Describe your relationship with your parents while growing up:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Who was the most significant person in your childhood and why?\par
}{\plain \f1 \par
}{\plain \f1 Which parent do you feel assisted you most in your growing years and why?\par
}{\plain \f1 }{\plain \ul\f1 Siblings:}{\plain \f1 \par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \par
}{\plain \f1 *******\par
}{\plain \f1 Name:\par
}{\plain \f1 Residence (city/state)\par
}{\plain \f1 Employment:\par
}{\plain \f1 Frequency and type of current contact:\par
}{\plain \f1 Describe your relationship with this sibling during childhood and adulthood:\par
}{\plain \f1 \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 Describe family traditions:\par
}{\plain \f1 \par
}{\plain \f1 What did you like best about growing up in your family?\par
}{\plain \f1 \par
}{\plain \f1 What would you change if you could?\par
}{\plain \f1 \par
}{\plain \f1 Are your parent(s) living?\par
}{\plain \f1 If not, how old were you at the time of their death:\par
}{\plain \f1 Please indicate which parent and the circumstances:\par
}{\plain \f1 \par
}{\plain \f1 Are your sibling(s) living?\par
}{\plain \f1 If not, how old were you at the time of their death:\par
}{\plain \f1 Please indicate which sibling and the circumstances:\par
}{\plain \f1 \par
}{\plain \f1 Describe the impact the death(s) had on you:\par
}{\plain \f1 \par
}{\plain \f1 How did you cope with the loss(es)?\par
}{\plain \f1 \par
}{\plain \f1 If your parents are still living, where do they reside?\par
}{\plain \f1 How often do you see them?\tab \tab \tab \par
}{\plain \f1 How often do you talk with them?\par
}{\plain \f1 \par
}{\plain \f1 What is the biggest disappointment you have had in your life?\par
}{\plain \f1 \par
}{\plain \f1 How did you handle it?\par
}{\plain \f1 \par
}{\plain \f1 What personal achievement are you most proud of?\par
}{\plain \f1 \par
}{\plain \f1 What are your personal goals?\par
}{\plain \f1 \par
}{\plain \f1 What are your career goals?\par
}{\plain \f1 \par
}{\plain \f1 What hobbies/leisure activities do you enjoy?\par
}{\plain \f1 \par
}{\plain \f1 Do you use any of the following?\par
}{\plain \f1 \tab }{\plain \ul\f1 ____\tab }{\plain \f1  alcoholic beverages\tab \tab Frequency:\par
}{\plain \f1 \tab _____ narcotics\tab \tab \tab Frequency:\par
}{\plain \f1 \tab _____ tobacco products\tab \tab Frequency:\par
}{\plain \f1 \tab Comments:\par
}{\plain \f1 \par
}{\plain \f1 Have you ever been arrested?  If so, please explain:\par
}{\plain \f1 \par
}{\plain \f1 Have you ever been affected directly or indirectly by:\par
}{\plain \f1 \tab _____Sexual Abuse\tab \tab _____Incarceration\par
}{\plain \f1 \tab _____Physical Abuse\tab \tab _____Alcoholism\par
}{\plain \f1 \tab _____Mental Abuse\tab \tab _____Therapy/counseling\par
}{\plain \f1 \tab _____Drug Abuse\tab \tab \tab _____Financial problems\par
}{\plain \f1 \tab Comments:\par
}{\plain \f1 \par
}{\plain \f1 Please list your strengths:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Please list any areas needing improvement:\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \b\i\ul\f1 Education\par
}{\plain \f1 \par
}{\plain \f1 High School attended (city, state) :\par
}{\plain \f1 Graduation date:\par
}{\plain \f1 College:\par
}{\plain \f1 Degree obtained:\par
}{\plain \f1 Year obtained:\par
}{\plain \f1 Vocational School:\par
}{\plain \f1 Area of Specialty:\par
}{\plain \f1 Year of Completion:\par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \b\i\ul\f1 Employment History}{\plain \i\f1 \par
}{\plain \f1 \par
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{\plain \f1 Current Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment:\par
}{\plain \f1 Location:\par
}{\plain \f1 Annual Income:\par
}{\plain \f1 Monthly net salary:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
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{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \tab \tab \par
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{\plain \f1 ********\par
}{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
}{\plain \f1 \par
}{\plain \f1 ********\par
}{\plain \f1 Previous Employer:\par
}{\plain \f1 Position:\par
}{\plain \f1 Dates of Employment\par
}{\plain \f1 Location:\par
}{\plain \f1 Reason for leaving:\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
}{\plain \f1 \par
}{\plain \b\i\ul\f1 Previous Marriages (if applicable)\par
}{\plain \b\ul\f1 \par
}{\plain \f1 Name of ex-spouse:\par
}{\plain \f1 \par
}{\plain \f1 Date of Marriage:\par
}{\plain \f1 \par
}{\plain \f1 How did you meet:\par
}{\plain \f1 \par
}{\plain \f1 Reason for divorce:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Date of divorce:\par
}{\plain \f1 \par
}{\plain \f1 How is the current marriage different:\par
}\pard \qc\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \tab \tab \tab \tab \tab }{\plain \b\ul\f1\fs28 MARRIAGE   QUESTIONNAIRE}{\plain \f1 \par
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{\plain \f1 \par
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{\plain \f1 Length of engagement:\par
}{\plain \f1 Date of marriage:\par
}{\plain \f1 Place of marriage (county, city, state)\par
}{\plain \f1 How and where did you and your spouse meet?\par
}{\plain \f1 \par
}{\plain \f1 Describe the strengths of your marriage:\par
}{\plain \f1 \par
}{\plain \f1 Describe some of the changes you would like to make in your marriage:\par
}{\plain \f1 \tab \tab \tab \tab \tab    \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 The following areas often present challenges to couples. Please explain how you 
as a couple manage these areas and resolve any existing conflict:\par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Acquiring and spending money:\par
}{\plain \f1 \par
}{\plain \f1 Children:\par
}{\plain \f1 \par
}{\plain \f1 Communication:\par
}{\plain \f1 \par
}{\plain \f1 Goals:\par
}{\plain \f1 \par
}{\plain \f1 Household chores:\par
}{\plain \f1 \par
}{\plain \f1 In-laws:\par
}{\plain \f1 \par
}{\plain \f1 Leisure time activities:\par
}{\plain \f1 \par
}{\plain \f1 Lifestyle:\par
}{\plain \f1 \par
}{\plain \f1 Priorities:\par
}{\plain \f1 \par
}{\plain \f1 Religion:\par
}{\plain \f1 Use of alcohol or other chemicals:\par
}{\plain \f1 \par
}{\plain \f1 Work:\par
}{\plain \f1 \par
}{\plain \f1 Other:\par
}{\plain \f1 \par
}{\plain \f1 What are important goals that you as a couple are working toward:\par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}{\plain \f1 What impact do you expect a new child to have on your relationship:\par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 Have you or would you consider marriage counseling?  If so, under what 
circumstance:\tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 What would cause you to divorce and why?\par
}{\plain \f1 \par
}{\plain \f1 Where have you lived as a married couple (places and dates)?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \i\ul\f1 For the father:}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 Describe yourself as a marital partner, including both your strengths and areas 
needing improvement:\par
}{\plain \f1 \par
}{\plain \f1 Describe your wife as a marital partner, including strengths and areas needing 
improvement:\par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 What do you have in common?\par
}{\plain \f1 \par
}{\plain \f1 How are you different?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 }{\plain \i\ul\f1 For the mother:}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 Describe yourself as a marital partner, including both your strengths and areas 
needing improvement:\par
}{\plain \f1 \par
}{\plain \f1 Describe your wife as a marital partner, including strengths and areas needing 
improvement:\par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 What do you have in common?\par
}{\plain \f1 \par
}{\plain \f1 How are you different?\par
}{\plain \f1 \par
}{\plain \f1 \par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \b\ul\f1 PARENTING QUESTIONNAIRE}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Describe an ideal home environment for children?\par
}{\plain \f1 \par
}{\plain \f1 What do you think are the most important values for a child to learn?\par
}{\plain \f1 \par
}{\plain \f1 What goals do you have in mind for your child(ren)?\par
}{\plain \f1 \par
}{\plain \f1 What do you want and expect from your child(ren)?\par
}{\plain \f1 \par
}{\plain \f1 What forms of discipline and guidance to you use (or expect to use)?\par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 Would you be willing to and/or capable of parenting a high-need or special needs 
child?\par
}{\plain \f1 \par
}{\plain \f1 If so, What strength and background do you have that will enable you to parent 
this type of child?\par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 How important to you is the teaching of your faith to your child?\par
}{\plain \f1 \par
}{\plain \f1 How will you do this?\par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 If you do not have children, describe your experiences with the children of others 
that would assist you as parents:\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 }{\plain \i\ul\f1 For the father}{\plain \f1 :\par
}{\plain \f1 What is (or will be) your greatest strength as a parent?\par
}{\plain \f1 \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 What is (or will be) your greatest challenge as a parent?\par
}{\plain \f1 \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 What is (or will be) your spouse\'92s greatest strength and challenge as a parent?\par
}{\plain \f1 \tab \tab \tab \par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 In what ways do you want your parenting to resemble your own parent\'92s 
behavior?\tab \tab \tab \par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}{\plain \f1 In what ways do you want your parenting to differ from your parent\'92s behavior?\par
}\pard \qc\sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}{\plain \i\ul\f1 For the mother:\par
}{\plain \f1 What is (or will be) your greatest strength as a parent?\par
}{\plain \f1 \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 What is (or will be) your greatest challenge as a parent?\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 What is (or will be) your spouse\'92s greatest strength and challenge as a parent?\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 In what ways do you want your parenting to resemble your own parent\'92s 
behavior?\tab \tab \tab \tab \par
}{\plain \f1 \par
}\pard \sl360\slmult1\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}{\plain \f1 In what ways do you want your parenting to differ from your parent\'92s behavior?\par
}{\plain \f1 \par
}{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \b\ul\f1 Adoption Motivation\par
}{\plain \f1 \par
}{\plain \f1 Why are you choosing to adopt?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Do you both want to adopt?\par
}{\plain \f1 \tab \tab \tab \tab \tab \par
}{\plain \f1 At the present time, are you attempting to conceive?\par
}{\plain \f1 \par
}{\plain \f1 When did you start thinking about adoption?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Who was the first to suggest adoption?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What was the other spouse\'92s response?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Have attempts to conceive been unsuccessful?\par
}{\plain \f1 \par
}\pard \qc\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \par
}{\plain \f1 Have you shared your plan to adopt with your family?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 If so, what was your family\'92s response to you choice to adopt?\par
}{\plain \f1 \tab \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What do you imagine will be the most positive impact this adoption will have on 
your family?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What will be the most challenging impact of this adoption?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Have you ever started or completed a home study in the past?\par
}{\plain \f1 \par
}{\plain \f1 If yes, please provide the name and location of the home study provider:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Was the home study completed?    \par
}{\plain \f1 \par
}{\plain \f1 Was the result of the home study favorable?\par
}{\plain \f1 }{\plain \b\ul\f1 Feeling Toward Adoption and Birth Parents}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Please provide any and all experience you have with family and friends who have 
adopted or were adopted:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Please list any previous adoption experience you have had yourself, whether 
successful or not:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What are some situations/feelings you believe birth parents struggle with in 
deciding to place a child for adoption?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Do you plan to tell you child that (s)he was adopted?\par
}{\plain \f1 \par
}{\plain \f1 How will you tell him/her?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 At what age do you plan to tell your child (s)he was adopted?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 How do you feel about an adopted child searching for his/her birth parents?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Would you assist or oppose this type of search?\tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 How?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 How open are you to meeting, sharing phone calls and corresponding with birth 
parents?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 }{\plain \b\ul\f1 Child Desired}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Age range:\par
}{\plain \f1 \par
}{\plain \f1 Race and ethnicity:\par
}{\plain \f1 \par
}{\plain \f1 Gender:\par
}{\plain \f1 \par
}{\plain \f1 Are you willing to adopt a child whose birth mother abused alcohol or drugs 
during her pregnancy?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Are you willing to adopt a child with special needs?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \b\ul\f1 Childcare Plan}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Which parent will be staying home with the child immediately following the 
adoption?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 How long will you be able to take off of work at the time of placement?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What type of daycare/sitter will you use when you return to work?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What long term plans have you made for your child\'92s care, if something were to 
happen to you?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Does your current health insurance cover adopted children as soon as the child is 
placed?\par
}{\plain \f1 \par
}{\plain \f1 If not, what are your plans to provide for your child\'92s potential medical needs?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \b\ul\f1 Description of Home Environment}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 # of bedrooms:                   # of bathrooms:                         square footage:\par
}{\plain \f1 \par
}{\plain \f1 # of levels:                           # of fire extinguishers:\par
}{\plain \f1 \par
}{\plain \f1 # and location of smoke detectors:\par
}{\plain \f1  \par
}{\plain \f1 adopted child\'92s room will be located:\par
}{\plain \f1 \par
}{\plain \f1 Please circle the amenities that your home currently has:\par
}{\plain \f1 \par
}{\plain \f1 living room \tab     dining room\tab  family room      kitchen        utility room  \par
}{\plain \f1 \par
}{\plain \f1 pool\tab     garage\tab      fence\tab  spa\tab       screened patio   security system\par
}{\plain \f1 \par
}{\plain \f1 If your home is adjacent to a body of water, please provide the name of the body 
or water and the protection from water:\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 We have lived in this home for the past ____ years.\par
}{\plain \f1 \par
}{\plain \f1 What made you choose to live in this neighborhood/area?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What do you live about it?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 What opportunities are there for children (i.e. parks, schools, etc.)?\tab \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Do you have a safety plan/escape route in case of emergency?\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \tab \tab \tab \tab \tab \tab \tab \tab \tab \par
}{\plain \f1 \par
}{\plain \f1 \par
}\pard \qc\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \b\ul\f1 Financial Statement\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 Income:\tab \tab \par
}{\plain \f1 \tab Husband\'92s annual salary\tab    gross:$\tab \tab \tab \tab net:$             \par
}{\plain \f1 \tab Wife\'92s annual salary\tab \tab    gross:$\tab \tab \tab \tab net:$\par
}{\plain \f1          \tab Bonus and Commission\tab    gross:$\tab \tab \tab \tab net:$\par
}{\plain \f1 \tab Dividends\tab \tab \tab    gross:$\tab \tab \tab \tab net:$\par
}{\plain \f1 \tab Other Income\tab \tab    gross:$\tab \tab \tab \tab net:$\par
}{\plain \f1 \par
}{\plain \f1 \tab \tab \tab \tab      TOTAL \tab \tab   \tab  \tab TOTAL\par
}{\plain \f1  \tab \tab \tab      GROSS INCOME:$ \tab   \tab   NET INCOME*:$\par
}{\plain \f1 \par
}{\plain \f1 Assets:\par
}{\plain \f1 \tab Cash in bank (savings):\tab \tab \tab \tab \tab     \tab       $\par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Cash in bank (checking):\tab \tab \tab \tab \tab \tab       $\tab \par
}{\plain \f1 \tab Stocks and bonds:\tab \tab \tab \tab \tab \tab \tab       $\tab \par
}{\plain \f1 \tab Pension/Retirement:\tab \tab \tab \tab \tab \tab       $\par
}{\plain \f1 \tab IRA/401K:\tab \tab \tab \tab \tab \tab \tab \tab       $\par
}{\plain \f1 \tab Accounts/Loans receivable:\tab \tab \tab \tab \tab       $\tab \par
}{\plain \f1 \tab }{\plain \ul\f1 Automobiles\par
}\pard \fi-720\li1440\tx1440\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 make/model:          \tab \tab \tab \tab year:         \tab \tab \tab \tab   \par
}\pard \fi-720\li1440\tx1440\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 balance due: $                 \tab \tab \tab value: $\tab \tab \tab \par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \tab make/model:          \tab \tab \tab \tab year:           \tab \tab \tab \tab      \par
}\pard \li720\tx720\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 balance due: $           \tab   \tab \tab value: $\tab \par
}{\plain \f1 make/model:          \tab  \tab \tab \tab  year:          \tab \par
}{\plain \f1 balance due: $         \tab    \tab \tab \tab value: $\par
}\pard \tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640
{\plain \f1 \tab Furniture and Personal Effects:\tab \tab \tab \tab \tab       $\par
}{\plain \f1 \tab }{\plain \ul\f1 Real Estate \par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 purchase price: $                      current value:$                                    \par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 amount owed:   $\tab \tab \tab \tab \par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 purchase price: $                      current value:$                                    \par
}{\plain \f1       \tab amount owed:   $\par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 purchase price: $                      current value:$                                    \par
}{\plain \f1  \tab amount owed:   $\par
}{\plain \f1 \tab Whole life insurance-      current cash value: $\par
}{\plain \f1 \tab Boat- \tab \tab \tab balance due:$\tab \tab value:$\par
}{\plain \f1 \tab ATV- \tab \tab \tab balance due:$\tab \tab value:$\par
}{\plain \f1 \tab Other:\tab \tab \tab balance due:$\tab \tab value:$\par
}{\plain \f1 \tab Other:\tab \tab \tab balance due:$\tab \tab value:$\tab \tab        \par
}{\plain \f1 \tab Other:\tab \tab \tab balance due:$\tab \tab value:$\tab \tab \tab \tab \tab        \par
}{\plain \f1 \tab \par
}{\plain \f1 \tab \tab \tab \tab \tab \tab \tab     \tab TOTAL ASSETS: $\par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 }{\plain \b\ul\f1 Liabilities}{\plain \f1 \par
}{\plain \f1 \par
}{\plain \f1 Automobile loan\par
}{\plain \f1 \tab Amount owed\tab \tab \tab $\par
}{\plain \f1 \tab Amount owed\tab \tab \tab $\par
}{\plain \f1 \tab Amount owed\tab \tab \tab $\par
}{\plain \f1 Boat loan\par
}{\plain \f1 \tab Amount owed\tab \tab \tab $\par
}{\plain \f1 Credit Card Balance\par
}{\plain \f1 \tab Visa\tab \tab \tab \tab \tab $\par
}{\plain \f1 \tab Master Card\tab \tab \tab \tab $\par
}{\plain \f1 \tab American Express\tab \tab \tab $\par
}{\plain \f1 \tab Discover\tab \tab \tab \tab $\par
}{\plain \f1 \tab Store _________________\tab $\par
}{\plain \f1 \tab Store _________________\tab $\par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Store _________________\tab $\par
}\pard \fi720\tx0\tx720\tx1440\tx2160\tx2880\tx3600\tx4320\tx5040\tx5760\tx6480\tx7200\tx7920\tqr\tx8640 
{\plain \f1 Store _________________\tab $\par
}{\plain \f1 Other\par
}{\plain \f1 \tab \tab _________________\tab $\par
}{\plain \f1 \tab \tab _________________\tab $\par
}{\plain \f1 \tab \tab _________________\tab $\par
}{\plain \f1 \par
}{\plain \f1 TOTAL LIABILITIES\tab \tab \tab $\par
}{\plain \f1 \par
}{\plain \b\ul\f1 Insurance:}{\plain \f1 \par
}{\plain \f1 \par
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    height: 40px;
    font-size: 14px;
    line-height: 40px;
    padding: 0 8px;
    box-sizing: border-box;
    background: #F4F2E9;
    border: 1px solid #BBB8B8;
    transition: background-color 300ms ease-out,
                color 300ms ease;
}

form#header_search input[type="text"] {
    width: 100%;
}
form#header_search input[type="text"]:focus {
    border-color: #A2D054;
    background-color: #fff;
    box-shadow: 0 0px 12px -4px #A2D054;
}



form#header_search input[type="button"] {
    position: absolute;
    top: 1px;
    right: 1px;
    opacity: 1;
    background: #DFDCCF;
    color: #463734;
    width: 125px;
    cursor: pointer;
    height: 38px;
    border: none;
}
form#header_search input[type="text"]:focus ~ input[type='button']:hover,
form#header_search input[type='button']:hover {
    background-color: #A5CE56;
    color: #fff;
}
form#header_search input[type="text"]:focus ~ input[type='button'] {
    background-color: #52AEDF;
    color: #fff;
}

</style>

<script>
function searchit(){
    
    // determine environment 
    var search_env 
    if (lycos_ad_www_server.indexOf(".pd.") > -1) {
       search_env = 'http://search51.pd.lycos.com/a/';
    } else if (lycos_ad_www_server.indexOf(".qa.") > -1) {
       search_env = 'http://search51.qa.lycos.com/a/';
    } else {
       search_env = 'http://search51.lycos.com/a/';
    }

var search_term = encodeURIComponent(document.search.search2.value)
var search_url = search_env+search_term;
window.open(search_url);

return false
}
</script-->
<style>
    .adCenterClass{margin:0 auto}
</style>
<div id="tb_ad" class="adCenterClass" style="display:block!important; overflow:hidden; width:916px;">

<div id="ad_container" style="display:block!important; float:left; width:728px ">
<script type="text/javascript">
if (typeof lycos_ad !== "undefined" && "leaderboard" in lycos_ad) {
  document.write(lycos_ad['leaderboard']);
}
</script>
</div>
</div>
</div>
<script type="text/javascript">
if (typeof lycos_ad !== "undefined" && "slider" in lycos_ad) {
  document.write(lycos_ad['slider']);
}
</script> <!-- added 7/22 -->
<div id="FooterAd" style="background:#DFDCCF; border-top:1px solid #393939; clear:both; display:none; width:100%!important; position:relative; z-index:999999!important; height:90px!important"> 
<div class="adCenterClass" style="display:block!important; overflow:hidden; width:916px;">
<div id="footerAd_container" style="display:block!important; float:left; width:728px">
<iframe id="lycosFooterAdiFrame" style="border:0; display:block; float:left; height:96px; overflow:hidden; padding:0; width:750px"></iframe>
</div>
</div>
</div>