A CHILD WAITS FOUNDATION ~ Grant Pre-Qualification Form
	1136 Barker Rd, Unit 12  Pittsfield, MA  01201  Phone: 866-999-2445
	Fax: 518-794-6243  Email: cnelson@achildwaits.org  Web: www.achildwaits.org
	Name:				Home Phone: _________________     Date:
	Complete Address: ______________________________________________________________________
	Applicants' Information
	First Name		Age	Occupation				Cell #
	Child to be Adopted
	(Picture and medical for child should be submitted with this form and are required.)
	Country: ____________   # of Required Trips to Country: _____   Expected Date of Final Trip: ____________
	Name		Age	Sex	Special Need
	Current Family Profile
	Number of Children:   Adopted: _____   Bio: _____					Number of children at home: _________
	Ages of children:
	Do you have any children with special needs?					Yes		No
	If yes, please explain:
	Financial Information
	Last Year's Income: $				Own Home:______ Rent: ______			House Value: $
	Projected Current Year's Income: $				Home Equity: $			Other Equity/Assets: $
	Savings: $				Retirement: $			Investments: $
	After paying bills and expenses each month, how much money is left?   $
	Adoption Costs
	Total cost for adoption including home study and travel:							$ ___________________
	Amount paid to date:		(If amount paid is less than 30% of total adoption					$ ___________________
	costs, your pre-qualification form will not be considered.  Please wait
	until a minimum of 30% has been paid before submitting this form.)
	Amount left to pay:							$ ___________________
	Of amount paid, how much has been from your own savings/earnings?							$ ___________________
	Funds currently available (i.e., personal savings or fundraising):							$ ___________________
	What other grants, loans, agency reductions or church support have you applied for or received?
	Please list amounts and providers below.
	Funding Source				Amount	Approved	Funds Received	Still Pending	Grant/Loan/ Donation
	1					Yes       No	Yes       No	Yes       No
	2					Yes       No	Yes       No	Yes       No
	3					Yes       No	Yes       No	Yes       No
	4					Yes       No	Yes       No	Yes       No
	Are family and friends providing financial help with this adoption?    Yes _______  No _______
	Name/Relationship								Amount
	1)
	2)
	3)
	4)
	Name of Adoption Agency: _______________________________________________________________
	Name of Home Study Agency: _____________________________________________________________
	Is Home Study Complete?  Yes _____     No _____
	Are there any past credit issues, such as bankruptcy or late payments?  Yes ______   No ______
	If yes, please explain: _________________________________________________________________
	Have you had child's referral evaluated by a US International Adoption Specialist?  Yes ____  No ____
	If yes, do you have a written report? Yes ____  No ____						If yes, please send a copy of written report.
	Special Family/Financial Circumstances to be Considered:
	If the Foundation determines that you meet the prequalification requirements, you will be contacted to receive an application.  Please note that meeting the preliminary qualifications does not guarantee grant approval or funding.