| 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. | |||||||||||