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ADOPTION DATA CARD, DSHS 10-114

INSTRUCTIONS

Why information is needed and legal authority:

According to RCW 26.33.300, an Adoption Data Card (DSHS 10-114) must be completed and filed with the clerk of the court on behalf of the petitioner for each individual adopted. Under the federal requirements of the Adoption and Foster Care Analysis and Reporting System (AFCARS), the State must report on all adoptions which occurred since October 1, 1994, and in whose adoption Title IV-B/IV-C agency has had any involvement. AFCARS reports on all other adoptions are encouraged but are voluntary. Reports on the following adoptions are mandated:

a. All children adopted who had been in foster care under the responsibility and care of the Department of Social and Health Services (DSHS) and who were subsequently adopted whether special needs or not and whether subsidies are provided or not.

b. All special needs children who were adopted in the State of Washington, whether or not they were in the public foster care system prior to their adoption and for whom non-recurring expenses were reimbursed.

c. All children adopted for whom an adoption assistance payment or service is being provided based on arrangements made by or through DSHS.

SECTION I. CHILD INFORMATION

Item 1 – 5	Self-explanatory.
Item 6	In general, a person’s race is determined by how others define them or by how they define themselves. In the case of
	young children, parents determine the race of the child.

White:	a person having origins in any of the original peoples of Europe, the Middle East, or
	North Africa.
Black or African American:	a person whose ancestry is any of the black racial groups of Africa.
American Indian/Alaskan Native:	a person having origins in any of the original peoples of North or South America
	(including Central American) and who maintains tribal affiliation or community
	attachment.

Asian:

Native Hawaiian or other Pacific Islander:

a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Item 7	Self- explanatory
Item 8	Use the State definition of special needs as it pertains to a child eligible for an adoption subsidy.
Item 9	Check the factor or condition for categorization as special needs. Check all that apply.
Item 10	Check the factor or condition as defined by the State and clinically diagnosed by a qualified professional. Check all that
	apply.
Item 11	Date child was placed with adoptive family, either on foster or adoptive basis.
Item 12	Date child was placed in foster care following most recent removal from birth family.

SECTIONS II. BIRTH PARENT INFORMATION

Item 1

Item 2

Item 3

Item 4

Item 5

Enter the year of birth for each birth parent. If the exact year of birth is unknown, enter an estimated year of birth. Race: see instructions and definitions under SECTION I., Item 6.

Self-explanatory.

Enter the month, date, and year of termination of parental rights (TPR), voluntary relinquishment or death of birth mother or father.

SECTIONS III.	PETITIONERS INFORMATION
Item 1	Enter the year of birth for each petitioner. If the exact year of birth is unknown, enter an estimated year of birth.
Item 2	Self-explanatory.
Item 3	Race: see instructions and definitions under SECTION I., Item 6.
Item 4	Self-explanatory.
Item 5	Self-explanatory.

ADOPTION DATA CARD

DSHS 10-114 (REV. 06/2001) (AC 07/2002)

SECTION IV. ADOPTION PLACEMENT INFORMATION

Item 1	Indicate the location of the individual or agency that had custody or responsibility for the child at the time of initiation of
	adoption proceedings.
Item 2	Indicate the individual or agency which placed the child for adoption.
	Public agency:	a unit of State or local government.
	Private agency:	a for-profit or non-profit agency or institution.
	Public DSHS & Private Agency:	a DSHS agency and a private agency.
	Birth parent:	the parent(s) placed the child directly with the adoptive parent(s).
	Independent Person:	a doctor, a lawyer, or some other individual.
	Tribal agency:	a unit within one of the Federally recognized Indian Tribes or Indian Tribal
		Organization.
Item 3	Indicate the prior relationship(s) the child had with the adoptive parent(s).
	Stepparent:	spouse of the child’s birth mother or birth father.
	Other relative of child:	a relative of the birth parents through blood or marriage.
	Foster parent:	the child was placed in a non-relative foster family home with a family
		that later adopted him or her. The placement could have been for the
		purpose of either adoption or foster care.
	Non-relative:	adoptive parent fits into none of the categories above.
Item 4	(a) Enter “yes,” if this child was adopted with a signed adoption support agreement;
	(b) If a monthly financial payment is being paid mark yes;
	(c) Enter the amount of the monthly maintenance;
	(d) If the child is eligible for medical services under Title XIX or XX (state or federal) mark yes;
	(e) If the adoption support claimed by the state is reimbursement under Title IV-E mark yes. (ask adoption support
	program manager if you don’t know the answer).
Item 5	Self-explanatory.

SECTION V AND VI. AGENCY OR INDIVIDUAL COMPLETING POST PLACEMENT REPORT AND INDIVIDUAL COMPLETING DATA CARD

All items are self-explanatory.

SECTION VII COURT INFORMATION

All items are self-explanatory.

This form is available for down load from the DSHS Intranet site: http://asd.dshs.wa.gov/html/oar_forms.htm in

Microsoft Word for electronic fill and on the DSHS Internet site: http://www.dshs.wa.gov/dshsforms/index.html in both Microsoft Word, for electronic fill and PDF, read only.

ADOPTION DATA CARD

DSHS 10-114 (REV. 06/2001) (AC 07/2002)

	DEPARTMENT OF SOCIAL AND HEALTH SERVICES	Return To:
	CHILDREN'S ADMINISTRATION	Return To:
	CHILDREN'S ADMINISTRATION	ADOPTIONS

ADOPTION DATA CARD

PO BOX 45713, OLYMPIA WA 98504-5713

According to RCW 26.33.300, an Adoption Data Card (DSHS 10-114) must be completed and filed with the clerk of the court on behalf of the petitioner for each individual adopted. No amended birth certificate will be issued until the data card has been completed and filed with the Department of Social and Health Services (DSHS). Data collection will be used to provide statewide adoption statistics.

I. CHILD INFORMATION

1. PLACE OF BIRTH (County/Country/Alien status):

2. STATE:

3. U.S. CITIZEN AT TIME OF PLACEMENT:

4. DATE OF BIRTH:

5. SEX:

Yes

Male

Female

6. RACE (Check all that apply):

7. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM

White

TO BE SPANISH/HISPANIC/LATINO?

No, not Spanish/Hispanic/Latino

Black or African American

Yes, Cuban

American Indian/Alaska Native

Asian

Yes, Mexican/Mexican American/Chicano

Native Hawaiian or other Pacific Islander

Yes, Puerto Rican

Other Spanish/Hispanic/Latino

8. DOES THIS CHILD HAVE SPECIAL NEEDS?

9. SPECIAL NEEDS BASIS (Check all that apply):

Yes

Not applicable

Racial/origin background

Medical conditions or mental, physical,

Part of Sibling group

Unable to determine

or emotional disabilities.

Other:

Age

10. MEDICAL CONDITIONS OF MENTAL, PHYSICAL, OR EMOTIONAL DISABILITIES (Check all that apply):

Mental retardation

Physical disability

Other medical disability:

Visual/hearing impaired

Emotional disability

11. DATE CHILD WAS PLACED IN HOME OF PETITIONERS:

12. DATE OF INITIAL FOSTER CARE PLACEMENT:

II. BIRTH PARENT INFORMATION

MOTHER'S INFORMATION

FATHER'S INFORMATION

1. YEAR OF BIRTH:

2. RACE (Check all that apply):

White

Black or African American

American Indian/Alaska Native

Asian

Native Hawaiian or other Pacific Islander

3. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM

TO BE SPANISH/HISPANIC/LATINO?

No, not Spanish/Hispanic/Latino

Yes, Cuban

Yes, Mexican/Mexican American/Chicano

Yes, Puerto Rican

Other Spanish/Hispanic/Latino

4. MARITAL STATUS AT TIME OF BIRTH:

Married

Single

Unable to determine

Married

Single

Unable to determine

5. TERMINATION OF PARENTAL RIGHTS (TPR):

Court ordered TPR date:

Date of Voluntary Relinquishment:

Date of Death:

ADOPTION DATA CARD

DSHS 10-114 (REV. 06/2001) (AC 07/2002)

III. PETITIONER(S) INFORMATION

	PETITIONER 1 INFORMATION		PETITIONER 2 INFORMATION
1. YEAR OF BIRTH:	2. SEX:	1. YEAR OF BIRTH:	2. SEX:

Male

Female

Male

Female

3. RACE (Check all that apply):

White

Black or African American

American Indian/Alaska Native

Asian

Native Hawaiian or other Pacific Islander

4. IS THIS PERSON OR THEIR PARENT/GUARDIAN CONSIDER THEM

TO BE SPANISH/HISPANIC/LATINO?

No, not Spanish/Hispanic/Latino

Yes, Cuban

Yes, Mexican/Mexican American/Chicano

Yes, Puerto Rican

Other Spanish/Hispanic/Latino

5. MARITAL STATUS AT TIME OF BIRTH:

Married Couple

Single Man

Married Couple

Single Man

Unmarried Couple

Single Woman

Unmarried Couple

Single Woman

IV. ADOPTION PLACEMENT INFORMATION

1. LOCATION OF AGENCY/

2. AGENCY/INDIVIDUAL WHICH PLACED CHILD FOR ADOPTION:

3. CHILD'S RELATIONSHIP TO

INDIVIDUAL WITH CUSTODY

Public agency

Birth Parent

ADOPTIVE PARENTS:

WHEN PETITION FILED:

Stepparent

Within state

Private agency

Independent person

Other relative of child

Another state

Name:

Foster Parent of child

Another country

Public DSHS and private agency

Tribal agency

Non-related

PA Name:

4. ADOPTION SUPPORT INFORMATION:

YES

a. Is there a signed adoption support agreement, if no, skip to number 5

. . . . . . .

. . .

b. Is monthly maintenance (state or federal) being received?

. . . . . . . . . .

. . . . . . .

. . .

c. Enter the amount of monthly maintenance: $

. . . . . . . . . . .d. Is Title XIX/XX medical being received?

. . .

. . . . . . . . .

. . . . . . . . . . .

. . . . . . . .

. . .

e. Is the child I-VE eligible?

. . .

. . . . . . . . . .

. . . . . . .

. . .

5. PLACEMENT INFORMATION (TO BE COMPLETED IF DSHS ADOPTION):

YES

Was child in state funded foster care prior to adoptive placement?

. . . . . . .

. . .

Was child placed with own (birth) siblings in this adoptive home?

. . . . . . .

. . .

Was child in prior adoptive or pre-adoptive placement?

. . . . . . .

. . .

V. AGENCY OR INDIVIDUAL COMPLETING POST PLACEMENT REPORT (CHECK ONE)

Department of Social and Health Services (DSHS)

Court employee

Report not

Washington Private Child Placement Agency

Other court appointed individual

completed

IV. INDIVIDUAL COMPLETING FORM

NAME:

TELEPHONE NUMBER:

ADDRESS:

CITY:

STATE:

ZIP CODE:

THE ABOVE INFORMATION IS COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

SIGNATURE:

VII. COURT INFORMATION (TO BE COMPLETED BY THE COURT)

PETITION NUMBER:

DATE PETITION FILED:

FINAL DECREE GRANTED:

COUNTY:

COUNTY CODE:

COURT CLERK OR DESIGNEE’S SIGNATURE:

This form is available for down load from the DSHS Intranet site: http://asd.dshs.wa.gov/html/oar_forms.htm in

Microsoft Word for electronic fill and on the DSHS Internet site: http://www.dshs.wa.gov/dshsforms/index.html in both Microsoft Word, for electronic fill and PDF, read only.

ADOPTION DATA CARD

DSHS 10-114 (REV. 06/2001)

Question	Answer
Form Name	Adoption Card Printable Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	wa adoption data, washington adoption data, wa form adoption card, intranet subcontinent gov

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