Adoption Card Printable Form PDF Details

The Adoption Data Card (DSHS 10-114) is a required Washington State form that petitioners must complete and file with the court clerk when finalizing an adoption. Mandated by RCW 26.33.300, it supports both state law compliance and federal reporting under the Adoption and Foster Care Analysis and Reporting System (AFCARS).

The form captures essential information about the child, including birthplace, race, special needs status, and placement circumstances. It also collects demographic data on the birth parents and the adoptive petitioners, covering marital status, race, and adoption history. Placing agencies provide additional placement details.

Together, these data points contribute to Washington's statewide adoption statistics, which help state agencies allocate support and resources to adoptive families and adopted children over time.

QuestionAnswer
Form NameAdoption Card Printable Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameswa adoption data, washington adoption data, wa form adoption card, intranet subcontinent gov

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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.

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

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

No

 

 

 

 

 

 

 

 

 

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

 

No

 

 

 

 

 

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:

 

 

 

 

 

 

 

1. YEAR OF BIRTH:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. RACE (Check all that apply):

 

 

 

 

 

 

2. RACE (Check all that apply):

 

 

 

 

 

White

 

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

Black or African American

 

 

 

 

 

 

Black or African American

 

 

 

 

 

American Indian/Alaska Native

 

 

American Indian/Alaska Native

 

Asian

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

 

 

Native Hawaiian or other Pacific Islander

Native Hawaiian or other Pacific Islander

 

 

 

 

 

 

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

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

 

TO BE SPANISH/HISPANIC/LATINO?

 

 

 

 

 

 

TO BE SPANISH/HISPANIC/LATINO?

 

 

 

 

 

No, not Spanish/Hispanic/Latino

 

 

No, not Spanish/Hispanic/Latino

 

Yes, Cuban

 

 

 

 

 

 

 

Yes, Cuban

 

 

 

 

 

 

 

 

Yes, Mexican/Mexican American/Chicano

Yes, Mexican/Mexican American/Chicano

 

Yes, Puerto Rican

 

 

 

 

 

 

Yes, Puerto Rican

 

 

 

 

 

 

Other Spanish/Hispanic/Latino

 

 

Other Spanish/Hispanic/Latino

 

 

 

 

 

 

 

 

4. MARITAL STATUS AT TIME OF BIRTH:

 

 

4. MARITAL STATUS AT TIME OF BIRTH:

 

Married

Single

Unable to determine

Married

Single

Unable to determine

 

 

 

 

 

 

 

 

5. TERMINATION OF PARENTAL RIGHTS (TPR):

 

 

5. TERMINATION OF PARENTAL RIGHTS (TPR):

 

Court ordered TPR date:

 

 

 

 

 

 

Court ordered TPR date:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Voluntary Relinquishment:

 

 

Date of Voluntary Relinquishment:

 

Date of Death:

 

 

 

 

 

 

 

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):

 

 

 

 

 

 

 

 

 

 

3. RACE (Check all that apply):

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

 

Black or African American

 

 

 

 

 

 

Black or African American

 

 

 

 

 

 

American Indian/Alaska Native

 

 

 

 

 

 

American Indian/Alaska Native

 

 

 

 

Asian

 

 

 

 

 

 

 

 

 

 

 

Asian

 

 

 

 

 

 

Native Hawaiian or other Pacific Islander

 

 

 

 

 

 

Native Hawaiian or other Pacific Islander

 

 

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

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

 

TO BE SPANISH/HISPANIC/LATINO?

 

 

 

 

 

TO BE SPANISH/HISPANIC/LATINO?

 

 

 

 

No, not Spanish/Hispanic/Latino

 

 

 

 

 

 

No, not Spanish/Hispanic/Latino

 

 

 

 

Yes, Cuban

 

 

 

 

 

 

 

 

 

 

 

Yes, Cuban

 

 

 

 

 

 

Yes, Mexican/Mexican American/Chicano

 

 

 

 

 

 

Yes, Mexican/Mexican American/Chicano

 

 

Yes, Puerto Rican

 

 

 

 

 

 

 

 

 

 

 

Yes, Puerto Rican

 

 

 

 

 

 

Other Spanish/Hispanic/Latino

 

 

 

 

 

 

Other Spanish/Hispanic/Latino

 

 

 

 

5. MARITAL STATUS AT TIME OF BIRTH:

 

 

 

 

 

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

NO

 

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

NO

 

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)

How to Edit Adoption Card Printable Form Online for Free

Complete the Adoption Data Card (DSHS 10-114) on FormsPal in minutes. The form covers 4 pages of child information, birth parent details, and petitioner data. You must file the completed form with the court clerk when you submit your adoption petition in Washington State.

How to Fill Out the DSHS 10-114 Adoption Data Card

Before you start, gather these documents:

  • The child's birth certificate
  • Placement agreement from the adoption agency
  • Special needs documentation (if applicable)
  • Your attorney's contact information

Follow these steps to complete each section:

  1. Child Information (Part A): Enter the child's full legal name, date of birth, birthplace, sex, and race. Indicate whether the child has special needs and whether adoption assistance will be received.
  2. Birth Parent Information (Part B): Provide the birth mother's and birth father's date of birth, race, and marital status at the time of the child's birth. Leave fields blank only when the information is genuinely unavailable.
  3. Petitioner Information (Part C): Fill in the full name, date of birth, race, marital status, and prior adoption history for each adoptive parent. Include their relationship to the child.
  4. Placement and Court Information (Part D): Record the placement date, placing agency name, and the county where you file the adoption petition. Include the court case number and hearing date.
  5. Sign and date the form: The petitioner or their attorney must sign at the bottom. File the signed form with the court clerk along with the adoption petition under RCW 26.33.300.

Frequently Asked Questions About the Adoption Data Card

Who must complete the Adoption Data Card?

The petitioner (the adopting person or couple) or their attorney must complete and file the DSHS 10-114 in Washington State. It is required for all adoptions, including step-parent adoptions, foster care adoptions, and adoptions of children with special needs.

Where do I file the completed form?

File the Adoption Data Card with the court clerk in the county where you submit your adoption petition. The clerk forwards the form to the Washington Department of Social and Health Services for statewide adoption reporting under the AFCARS federal mandate.

Can I submit the form online?

Currently, the DSHS 10-114 must be filed in person with the court clerk as part of the adoption petition package. You can fill it out online using FormsPal and then print and sign the completed form before filing.

What if information about the birth parents is unavailable?

Birth parent fields may be left blank when the information is genuinely unknown. Complete all petitioner and child fields as fully as possible to avoid delays in your adoption hearing.

Is this form required for international adoptions?

The DSHS 10-114 applies to adoptions finalized in Washington State courts. For international adoptions that are re-domesticated in Washington, consult your attorney to confirm whether filing is required.

For related forms, see the Certificate of Adoption form, the New York Adoption Form, and the Georgia Adult Adoption Petition Form. You can also access the Alabama Adoption Report and the Kansas Report of Adoption in the FormsPal library.

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