Let Me Begin by Saying That We Look Forward to Working with You

1515 Mockingbird Lane, Ste. 560 Charlotte, NC 28209 www.saintmaryadoption.com 704 527 7673

SaintSaint Mary Mary International International Adoptions’ Adoptions’ Revised Revised HomeHome Study Study Instructions Instructions and and Template Template

96.47a96.47a

th NovemberNovember 17 17th, 2015, 2015

1 Hello Social Worker,

Let me begin by saying that we look forward to working with you.

As it is common practice, we have a template to help the home study agency working with the family to be guided in meeting all the state, federal, and country requirements.

We understand that the needs of each family are different. We understand that there are differences in state requirements.

Therefore, although this template is designed to help guide you, it is NOT to be exactly applied to each family the same way. Rather, it should be applied differently considering each family’s differences based on the social worker’s clinical evaluation of each family.

The primary objective in using a template, with fictional people and their fictional lives is to give the social worker of sense how much detail is needed each section.

In the template, we’ve used different colors.

The blue color is used in order to get your attention on particular information which is important and we feel the social worker needs to spend the necessary time in these sections to communicate what the language means so that the adoptive parents understand it. It is upto the social worker then to work with each family to specify the particular language in each home study, based on his/her clinical evaluation of each adoptive parent.

The green color addresses sections where the social worker will have to implement their clinical judgement consistent with each family and apply the type of information in consideration of each family’s case. In green, there also may be some sections which will not apply to the family at all, such as, DUI, Arrests.

Highlighted in blue, is where we’ve made explanations and/or clarifications which are addressed to the social worker.

Again, let us stress that we understand each family is different and so are the circumstances for each study and its findings. We trust these will be portrayed to us with the special evaluation of the social workers’ clinical evaluation for each family.

If you have any questions, please let us know. We want to be involved in this process and we want to work together for the best interest of each family.

You can call me at: 704 527 7673

God Bless,

Nick Ratchev, MBA, Operations Manager

2 I know I previously said that this is just a fictional template, but before we get started, let me just say one more time that each statement in the home study needs to disclose the truth about the particular family.

HOME ASSESSMENT

Primary Provider: Saint Mary International Adoptions

Exempt Provider: this is your agency

Adoption Country: Bulgaria

The prospective adoptive parents are Mark Joseph and Tracy Frances Smith, married since June 17, 1995 residing as a family at 16 Pine Lane, Spring Ville, NC 28530.

They are the only residents of their household. Mark is a United States citizen by birth in the United States. Tracy is also a United States citizen by birth in the United States. They have met North Carolina’s six-month residency requirements (Mark has lived in North Carolina for one year and Tracy has lived in North Carolina for one year).

Detailed information is provided as follows:

Husband: Mark Joseph Smith D.O.B: December 15, 1967 Place: Baltimore City, Maryland Passport #:

Wife: Tracy Frances Smith D.O.B: March 25, 1969 Place: Manitowoc County, Wisconsin Passport#:

Additional adult household member: (including children that are away for college):

D.O.B: Place: SSN# or Alien Registration Number (if any):

Education: Mr.: Bachelor of Science in Biology Bachelor of Science in Physician Assistant Studies

Mrs.: Bachelor of Science in Exercise Physiology Masters degree in Health Administration

3 Occupation: Mr.: Physician Assistant, Carolina Medical Center Mrs.: Health System Specialist, Mercy Hospital

Religion: Mr.: Catholic Mrs.: Non-denominational

SUMMARY OF CONACTS

Home visit and group interview with Mark and Tracy: 6-13-15

Individual face to face interview with Tracy: 6-12-15 in the agency’s office (or in the applicants’ house)

Individual face to face interview with Mark: 6-12-15 in the agency’s office (or in the applicants’ house)

Second group interview with Mark and Tracy in the agency’s office: 6.25.15

Individual face to face interview with Josiah (10 years old biological son) in the family home: 6-13-15.

Individual face to face interview with any additional adult household member: 6.15.15

(Including children that are 10 years or older and even away for college. In case the Children are away for college, the interview is not strictly necessary to be face to face; it can be on the phone but the home study needs to state that it was on the phone and the reason for that.)

Numerous contacts via telephone and email stating May 12, 15 until finalization of home study on: 7.15.15.

MOTIVATION FOR ADOPTION

Mark and Tracy were married in 1994. Having a family with children is a natural part of the plan they have for their life together.

Due to infertility issues they have not conceived biologically and would like to add children to their family through adoption. Mark and Tracy agree that adoption is the option they want to pursue.

They want to provide a loving, stable and supportive family life for children who do not have one. They know and have experienced the true joy that children bring into your life from children of family and friends, and they want to extend their family through adoption. Mark and Tracy each stated that their lives have been blessed, and they want to

4 share their blessings with children. They are thrilled about their decision to adopt and are excited about being involved in the adoption process.

They have chosen to pursue a foreign adoption because they believe this need is much greater abroad. Mark and Tracy desire to adopt children from the country of Bulgaria because of Tracy’s European and Mark’s Slavic heritage. They also like the country and they are already knowledgeable about the Bulgaria culture, people, and traditions.

Friends and family members are supportive of their adoption plan. They will provide help in the form of welcoming the child into their home and family traditions as though the child were born biologically from Mark and Tracy.

The following language is consistent with the adoption education courses. The social worker shall discuss with the family, the family’s thoughts and understanding of the information provided in the preparation course. The social worker shall then consider the language below, discuss it with the family, and decide if anything needs to changed, and or added, to reflect the family’s situation.

Mark and Tracy understand adoption risks such as emotional vulnerability, delays, and the possibility of the child’s inadaptability that may arise after the placement has been made. Mark and Tracy have also been informed about the issues related with children who have been institutionalized or in foster care. They understand the dynamics of child abuse and neglect and how any abuse or neglect they personally may have suffered in the past may affect a child they are parenting who has been abused or neglected. This worker believes that they are adequately prepared to parent a child who has been abused or neglected. It is this worker’s opinion that Mark and Tracy’s motivation for adoption will have a positive effect on their ability to parent an adopted child.

Note to social worker: Again, this is an example. If the family is looking to adopt just one child, or up to three, or whatever the case may be, than the language in green needs to change to reflect the family’s situation. The age may also need to change per family’s wishes, social worker evaluation and foreign country requirements.

Mark and Tracy are looking to adopt up to two children of either sex, up to four years of age, healthy or with special needs without any specific restrictions on a case by case basis from the Convention country of Poland.

The language below, is a good opportunity for the clinical worker to grasp a sense of how well the family has been prepared as a result of taking the Hague required adoption classes. In addition, this is a good opportunity for the family to learn more about these issues common to international adoption, and Bulgaria’s region in particular as provided in the education course (1hr on Bulgaria). The family and the social worker shall work together to determine which issues they would be open to, and which ones they wouldn’t be able to handle. The social worker should provide assistance, clinical advice, and discuss his/her clinical evaluation in the home study in regards to the specific description of the child that the social worker approves to be placed with the family.

5 Mark and Tracy will consider all medical and behavioral conditions that include; history of poor prenatal care, no family history available, history of ear infections, malnutrition, delays in speech, umbilical hernia, developmental conditions, ears/hearing problems, genital/urinary/intestinal problems, orthopedic abnormalities, prematurity, birth weight less than five pounds, history of respiratory infections, heart murmur, birthmarks or scarring, mild infant rickets, cranial/facial abnormalities, digestive problems, poor vision or eye problems, heart conditions, anemia, epilepsy, FAS, hypertension, arthrogyposis, hepatitis B & C or undescended testis. This worker believes that Mark and Tracy understand the difficulties of raising a child with any issues and that they are willing to access all services benefiting the child. It is the opinion of this caseworker that Mark and Tracy understand an adopted child may experience identity problems and separation and loss issues as he or she grows. They are willing to seek counseling for the child should the need arise.

The language in green is highlighted in this color to bring it to your attention, as it reflects an opinion which the social worker shall be willing to stand behind, or if not, adjust the language to reflect the family’s situation consistent with the worker’s clinical evaluation.

Note to social worker: Again, this is an example. If the family is looking to adopt just one child, or up to three, or whatever the case may be, than the language in green needs to change to reflect the family’s situation. The age may also need to change per family’s wishes, social worker evaluation, and foreign country requirements.

Mark and Tracy are interested in adopting up to two children of either sex under the age of four years healthy or special needs without any specific restrictions on case by case basis.

ADDRESSING THE CONEVETION COUNTRY SPECIFIC REQUIREMENTS

This language below is in blue because it addresses the foreign country requirements. If the family does not agree with, and be willing to comply with the Bulgarian requirements, they will not be able move forward.

Although, these requirements have been disclosed to the family, and they have already been discussed before they’ve become our agency’s clients, please remind them of the age requirements of Bulgaria stated below. If the family has any questions, or any doubt about these requirements, please note their file to indicate this, and please direct them to us for further explanations and clarification if needed.

6 According to 8CFR 204.311(q) the adoptive parents have to meet the Convention country of Bulgaria specific requirements as they are stated below:

The adoptive parents must be at least 15 years older than the adoptive child. There should not be more than 50 years age difference between the adoptive child and the younger spouse and 55 years age difference between the child and the older spouse. When a child is adopted by a single mother, the lower age difference (of 50 years) should be considered. Bulgaria does not have a specific length of marriage requirement. Single women may also apply to adopt. Bulgarian adoption authorities do not have any specific income requirements. As long the adoptive parents are approved by CIS and have their CIS approval, that serves as the criteria for eligibility to that regard. Both adoptive parents have to make the trips to Bulgaria (two trips are required at this time), the first to meet the child/ren, the second to finalize the adoption and bring the child home. The adoptive parents need to apply for adoption with all of the documents required by Bulgarian Central Authority and Courts; the documents have to be submitted in original and they must be translated and apostilled. The adoptive parents need to keep the documents current by updating them according to the Bulgarian legal requirements. The adoptive parents are required to attend the US Embassy’s visa interview for the adopted child/ren and to submit all of the required documentation.

In light of those specific requirements and all facts relevant to the adoptive parents eligibility for adoption in the Convention country of Bulgaria this social worker confirms that Mark and Tracy Smith are suitable to adopt from the Convention country of Bulgaria.

DESCRIPTION OF ADOPTIVE PARENTS

SOCIAL SUMMARY OF ADOPTIVE FATHER

In this section, we kindly ask that each family member has their own, separate paragraph.

As the rest of the template, this section is very much functional. The characters and their lives are made up. However, we’ve done this to communicate the amount of detail that is appropriate to discuss family members, their situations, their relationships. Again, this is just a suggestion. If the social worker feels that there are circumstances that shall be given more attention and lengthier description, please use your clinical judgement to do so at any place.

I have personally seen Mark Smith and I have personally spoken to him alone.

Mark Smith was born December 15, 1967 in Baltimore City, Maryland. He is the older of two children born to Kevin and Melanie Smith.

7 In each section, there needs to be a statement regarding the history of mental health and substance abuse issues. In our example, no one has these issues. HOWEVER, if they are applicable to the family members, please disclose that in detail including when it started, how it has been treated, and if it has been resolved, how it was resolved.

Each person of the relatives shall be asked the question whether they are supportive of the adoptive family’s decision to pursue international adoption.

Mr. Kevin Smith is sixty-six years old at the writing of this document. He is in good health with no history of mental health or substance abuse issues. He has a high school education and computer certification. Mark’s father is described as being very loving, outgoing, and loyal to his family. He is retired from his job as a civilian employee with the Department of the Army in the Corps of Engineers. He has always been devoted to and involved in the life of his family. He is supportive regarding the adoption and accepts being a grandfather to children not born to his son’s wife.

Mrs. Melanie Smith is sixty-five years old at the writing of this document. She is in good health with no history of mental health or substance abuse issues. She has a high school education. Mark’s mother is described as being very loving and outgoing. She is a homemaker who also worked some as a secretary to help provide for the family. She has always been devoted to her family and involved in her children’s school activities. She is supportive regarding the adoption and accepts being a grandmother to children not born to her son’s wife.

Mark’s father and mother have been married for 45 years and currently reside in Peoria, Illinois. The family maintains a close relationship. Mark has always maintained an excellent relationship with his father and mother. He demonstrates great respect for both of his parents. Mark maintains contact with his father and mother through frequent visits and telephone calls.

Mark has a younger sister, Mary Thurman. Mary is 42 years old at the time of this document. She is married to Hugh Thurman. Mary and her husband have three children together. The family lives in Pasadena, Maryland. Mary is employed as a dental hygienist and her husband is employed as an engineer. Mark describes his sister as very supportive and loving. They continue to have a close relationship and visit each other frequently. Mark and Tracy enjoy spending time with their children and often take the children to theme parks and other activities.

There are no reports of substance abuse, mental illness or health problems with Mark’s sister or her family. She is supportive regarding the adoption and accepts being an aunt of children not born to her brother’s wife.

Mark recalls his childhood with fond memories. He grew up in Pasadena, Maryland. The town provided a high quality and secure way of life. Mark’s family was traditional in practice and belief. As a child, Mark was taught the importance of respect, honesty,

8 responsibility, dependability and family. He was also involved with and excelled in academic clubs. Mark was an excellent student in school.

If the adoptive father or/and mother has European / Bulgarian heritage, please include a paragraph which describes how the traditions were kept in the family in each of their sections (if applicable) for example. Below is just one example of how this could be done:

Mark’s maternal grandmother is Bulgarian and the family feels connected to the Bulgarian history, traditions, and culture. At Mark’s family gatherings, her family would cook traditional Bulgarian foods such as poppy seed bread, moekliesel, and pierogies. Mark recalls dancing horas and waltzes at weddings. Attending their Catholic church weekly was very important in her family and continues to be to this day. Her aunt is a Franciscan nun in Minnesota and her brother is a youth pastor at his church. She is sharing her heritage and background with her son Alex, and they will continues this with their adopted children. They report they will take extra care to buy things from their birth country and to encourage an interest in their birth country.

Mark attended Loyola College in Baltimore, Maryland following graduation from high school. He graduated from Loyola College in 1987 with a Bachelor of Science in Biology. Mark entered the United States Army after college graduation in 1987. He served in Medical Service Corps from 1987-1997. He was honorably discharged from the United States Army in 1997. He returned to college and graduated cum laude with a Bachelor of Science in Physician Assistant Studies from South University in Savannah, Georgia in 2003. Mark returned to the United States Army as a Commissioned Captain in 2008. Details of his military history will be discussed in greater detail later in this document.

Mark is currently employed as a Physician Assistant within United States Army. His annual salary is $81,566. As previously explained, Mark has served on active duty with the United States Army for a total of over 9 years as of the writing of this document.

Mark greatly enjoys working for the United States Army due in part to the respect he has for his fellow medical professionals and the dedication shown by his co-workers and patients. He describes a strong commitment to providing excellent patient care. Mark enjoys spending time with his wife at home and traveling as well as in physical activities including skiing and running together. Mark demonstrates a high level of motivation and responsibility as well as loyalty to his family. He is also fun-loving and greatly enjoys the outdoors.

Please note the following paragraph as an example if any of the adoptive parents has a DUI, or any other arrests. It is very important that the incident is described in detail according to the court and police documents which the social worker has requested, and has personally seen. Each issue/arrest shall disclose what happened, when, how it was resolved, and how the adoptive parents feel about what happened, and what they learned from the experience. A clinical evaluation is needed to

9 determine whether despite any possible issue/arrest, the adoptive parent is still deemed eligible. A social worker shall include such a statement if he/she approves the adoptive parent.

Mark Smith was charged with Driving under the Influence in Chatham County, Georgia on February 5, 2002. He had recently returned to school to pursue his Physician Assistant degree and was at a restaurant with classmates after their first exams. He was pulled over on his way home. He deeply regrets his action. The judgment from the Chatham County, Georgia has been seen and I have discussed this issue with Mark. He pleaded guilty to the offense of Driving under the Influence. He was ordered to attend a DUI School, perform 40 hours of community service, and pay fines and fees in the amount of $1246. He was also placed on probation for 12 months. He completed all the above necessary requirements to regain his driver’s license and has had no further incidents.

Mark stated that he does not consume alcohol on a regular basis and he has no history of substance abuse. Mark states that this has been his only arrest and conviction. He has met this legal situation with cooperation and has taken responsibility for the arrest and the disposition. He has been able to verbalize his understanding of his responsibility to others, including a child, and states that he is very confident that this mistake will not be repeated. I have been able to discuss the circumstances of the DUI, and I am confident that this is a not a consistent behavior and that Mr. Mark Smith does not present a risk to a child.

When the adoptive parent provides any information about any arrests, convictions, history of substance abuse or violence or any other incident even if it did not result in an arrest, the social worker shall obtain a written statement signed under penalty of perjury from the client for your records and scan a copy to us as well.

When the adoptive parent(s) describe any (and all) incident(s) they are disclosing, they need a written statement in (3 originals) signed under penalty of perjury (one for our records, one for your records, and one for USCIS)

The adoptive parents may use the following template to report their incidents

I …………………certify under penalty of perjury under US law:

Briefly describe in your own words (Adoptive parent) what happened

10 ……………..signature

printed name

Again, the social workers shall remind the adoptive parents that the adoptive parents shall provide a certified copy of the court and/or police report so that the adoptive parent will present it to CIS along with the home study. Please scan us a copy as well.

The social worker shall be sure that the following questions be asked to each adoptive parent directly. The language in green which has also been underlined, shall be reviewed carefully by the social worker so that he/she may be sure that the questions are asked of each parent.

Mark is a healthy and attractive 42-year-old Caucasian male. He is 5 feet 8 inches tall and weighs 170 lbs. He has brown hair, brown eyes and a medium complexion. He is in excellent physical health, as reflected in the medical report. When asked, Mark Smith denied any history as an offender whether in the United States or abroad. He denied any history of substance abuse, mental or emotional health problems, or any behavioral issues. He denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. He denied any history of alcohol abuse, controlled substances abuse or other substances impaired his ability to fulfill obligations at work or home or crate other social or interpersonal problems that may adversely affect his ability as an adoptive parent. He indicated that if needed, he would not hesitate to seek and attend counseling due to any adoption issue. When asked, he denied ever being involved with any prior home studies or having been the subject of an unfavorable home study or ever being rejected as a prospective adoptive parent and ever being a subject of a home study terminated without completion related to any adoption or any form of foster care or other custodial care.

This social worker asked Mark Smith the following direct questions and he replied “no” to each question: 1. Have you ever been denied as prospective adoptive parent or been the subject of Important an unfavorable home study? questions 2. Have you ever begun a home study process in relation to an adoption or to any form of foster or other custodian care of a child that was not completed?

Of course, if the answer to these isn’t “no”, please provide the correct answer. Of course, if the answer to these isn’t “no”, please provide the correct answer.

11 In case there was a prior or terminated home study, the social worker shall provide the following information:

1. Identify the agency involved in each prior home study; 2. When the prior home study process began; the date prior home study was completed; 3. Whether the prior home study recommended for or against finding the applicant suitable for adoption, foster care or other custodial care of a child; 4. If a prior home study was terminated without completion the current home study must indicate when the prior home study began, the date of termination and the reason for the termination; 5. If there was a non favorable prior home study for the adoptive father a copy of it needs to be presented together with this home study.

As I have personally seen Mark Smith, and I have spoken with him alone, I find him suitable to properly parent adoptive children.

SOCIAL SUMMARY OF ADOPTIVE MOTHER

In this section, we kindly ask that each family member has their own, separate paragraph.

As the rest of the template, this section is very much functional. The characters and their lives are made up. However, we’ve done this to communicate the amount of detail that is appropriate to discuss family members, their situations, their relationships. Again, this is just a suggestion. If the social worker feels that there are circumstances that shall be given more attention and lengthier description, please use your clinical judgement to do so at any place.

I have personally seen Tracy Smith and have personally spoken to her alone.

Tracy was born on March 2, 1967 in Manitowoc County, Wisconsin. She is the middle of four children born to Dr. William and Margaret Coyle.

In each section, there needs to be a statement regarding the history of mental health and substance abuse issues. In our example, no one has these issues. HOWEVER, if they are applicable to the family members, please disclose the in detail including when it started, how it has been treated, and if it has been resolved, how it was resolved.

Each person of the relatives shall be asked the question whether they are supportive of the adoptive family’s decision to pursue international adoption.

Dr. William Coyle is 69 years old at the time of this document. Dr. Coyle is in good physical health. There are no reports of substance abuse or mental illness issues. Dr. Coyle has a PhD in History and is a retired high school history, civics, and religion teacher. He also served in and retired from the United States Army Reserves as a civil

12 affairs officer. Tracy describes her father as a gentle, kind, and caring man who is eager to assist anyone in need. He raised his children with an appreciation for family and was always very involved in activities with his wife and children. He is supportive regarding the adoption and accepts being a grandfather to children not born to his daughter.

Mrs. Margaret Coyle is 67 years old at the time of this document. Mrs. Coyle is in good physical health. There are no reports of substance abuse or mental illness issues. Mrs. Coyle has a Bachelor’s degree in English. She is a homemaker who volunteers with various community and charitable organizations. Tracy’s mother is described as energetic, kind, intelligent and dedicated to the well-being of her family. She is supportive regarding the adoption and accepts being a grandmother to children not born to her daughter.

Tracy demonstrates great respect and admiration for her parents. She credits them with teaching her the importance of being responsible and dependable. Tracy describes a childhood filled with fun and various family activities. She continues to have a close relationship with her father and her mother. Tracy’s parents live in DePere, Wisconsin. They maintain frequent contact through visits, phone calls, and emails.

Tracy’s older sister, Elizabeth Trever lives in Eagan, Minnesota. Elizabeth Trever is 44 years old at the time of this document. She is married to Todd Trever and they have 6 children together. Their youngest 2 children are adopted from Liberia. Elizabeth has a Bachelor’s degree in trumpet performance and home schools their children. Elizabeth is very involved in her church’s music program. Tracy describes a very close relationship with her sister, Elizabeth. She describes Elizabeth as very smart, outgoing, and dependable. They maintain frequent contact through phone calls, emails and visits.

There are no reports of substance abuse or mental illness with Elizabeth Schmitter or any member of her family. Elizabeth is supportive regarding the adoption and accepts being an aunt of children not born to her sister.

Tracy has a twin sister, Susan Miller. Susan is 40 years old at the time of this document. She is married to Travis Miller and they reside in Louisville, Kentucky. They have no children. Susan is employed as a personal caregiver and her husband is currently a seminary student who works part-time in a bank. Tracy describes Susan as serious and thoughtful and as her best friend. Tracy continues to enjoy a close relationship with her sister, Susan, and maintains frequent contact through phone calls, emails and visits.

There are no reports of substance abuse or mental illness with Susan Myers or any member of her family. Susan is supportive regarding the adoption and accepts being an aunt of children not born to her sister.

Tracy’s younger brother, Darel Coyle, is 29 years old at the time of this document. He is not married and does not have any children. He is a musician and lives in Portland, Oregon. Tracy describes her brother, David, as artistic and energetic. She has a close relationship with her brother, despite the physical distance between them. They maintain

13 frequent contact through phone calls, emails, and visits. There are no reports of substance abuse or mental illness with David Coyle. He is supportive regarding the adoption and accepts being an uncle of children not born to his sister.

Tracy’s siblings and families are very supportive to her decision to adopt.

Tracy attended Mannheim American High School in Mannheim, Germany. She was an average student who excelled in sports and was involved in the music program. After graduating from high school, Tracy enrolled in the University of Wisconsin in Green Bay, Wisconsin. She graduated with a Bachelor of Science in Biology. While attending college, she was involved in sports and the Army ROTC and also worked as a nurse’s aid in a nursing home. After college graduation, she enlisted in the United States Army and served as a Platoon Leader and Company Commander in medical field units. She then obtained her Masters degree in Healthcare Administration from Baylor University. Tracy’s military history will be discussed in more detail later in this document.

Tracy describes herself as level-headed, quiet and as having a gentle nature. She describes her ability to handle difficult situations calmly and rationally. She is responsible and confident in her ability to achieve her goals. She is very competent and capable. Tracy is excited about becoming a mother and enjoys being a wife. She enjoys spending time with her husband both at home and outdoors in activities such as running, golfing, and attending sporting events.

If the adoptive father or/and mother has European/Bulgarian heritage, please include a paragraph which describes how the Polish traditions were kept in the family in each of their sections (if applicable) for example. Below is just one example of how this could be done:

Tracy’s maternal grandmother is Bulgarian and the family feels connected to the Bulgarian history, traditions, and culture. At Mark’s family gatherings, her family would cook traditional Bulgarian foods such as poppy seed bread, moekliesel, and pierogies. Tracy recalls dancing horas and waltzes at weddings. Attending their Catholic church weekly was very important in her family and continues to be to this day. Her aunt is a Franciscan nun in Minnesota and her brother is a youth pastor at his church. She is sharing her heritage and background with her son Alex, and they will continues this with their adopted children. They report they will take extra care to buy things from their birth country and to encourage an interest in their birth country.

Tracy is employed in a civil service capacity as a Health System Specialist at Mercy Hospital, Spring Ville North Carolina. Her annual salary is $70,949. She has been employed in this position for one year. Tracy greatly enjoys and is dedicated to her work. She is a member of the American College of Healthcare Executives.

The social worker shall be sure that the following questions be asked to each adoptive parent directly. The language in green which has also been underlined, shall be reviewed

14 carefully by the social worker so that he/she may be sure that the questions are asked of each parent.

Tracy is a healthy and attractive 40-year-old Caucasian woman who is 5 feet 5 inches tall and weighs 120 lbs. She has sandy blonde hair, blue eyes, and a fair complexion. She is excellent physical health, which is reflected in the medical report. When asked, Tracy Smith denied any history as an offender whether in the United States or abroad. She denied any history of substance abuse, mental or emotional health problems or any behavioral issues. She denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. She denied any history of alcohol abuse, controlled substances abuse or other substances impaired her ability to fulfill obligations at work or home or crate other social or interpersonal problems that may adversely affect her ability as an adoptive parent. She would not hesitate attending counseling if needed due to adoption issues. When asked, she denied ever being involved with any prior home studies, ever being the subject of an unfavorable home study or ever being rejected as a prospective adoptive parent and ever being a subject of a home study terminated without completion related to any adoption or any form of foster care or other custodial care.

This social worker asked Tracey Smith the following direct questions and she replied “no” to each question: Important 1. Have you ever been denied as prospective adoptive parent or been the subject of questions an unfavorable home study? 2. Have you ever begun a home study process in relation to an adoption or to any form of foster or other custodian care of a child that was not completed?

Of course, if the answer to these isn’t “no”, please provide the correct answer.

In case there was a prior or terminated home study, the social worker shall provide the following information

1. Identify the agency involved in each prior home study; 2. When the prior home study process began; the date prior home study was completed; 3. Whether the prior home study recommended for or against finding the applicant suitable for adoption, foster care or other custodial care of a child; 4. If a prior home study was terminated without completion the current home study must indicate when the prior home study began, the date of termination and the reason for the termination; 5. If there was a non favorable prior home study for the adoptive mother a copy of it needs to be presented together with this home study.

As I have personally seen Tracy and I have spoken with her alone, I find her suitable to properly parent adoptive children.

15 CHILDREN AT HOME

Even if there are no children at home, please include this section title, and state: “There are no children in family” under the title.

If there are children, the social worker shall spend time with the children in an age appropriate manner to interview them. The social worker shall again, in an age appropriate manner, report in this section his/her interaction with the children, and talk about their thoughts, if any or if appropriate, about the upcoming adoption. The social worker shall be sure to do a separate interview according your state’s age requirements for such interview. For example, in NC, at age 10, the social worker is required to interview the child.

Josiah Smith is 12 years old at the writing of this document. His date of birth is October 3, 1996. He is the eldest biological child of Tracy and Mark. He has blond hair and blue eyes. His parents describe him as conservative and quiet and say that he is working at determining where he fits in now that he is in his "tween" years. Josiah does very well in school. He is in the sixth grade and attends the local middle school. He enjoys reading, playing cards and board games as well as video games. His favorite sport is soccer. This social worker had a separate face to face interview with Josiah. He is excited about adopting a little sister and says that he thinks it will be nice for his mother to have another female in the house.

Ethan is the Smith’s youngest child. He is 5 years old at the writing of this document. His date of birth is September 11, 2003. Ethan has red hair and green eyes. Ethan is in kindergarten at the same local elementary school that Noah attends. Ethan tries very hard to keep up with his older brothers. He is a "Daddy's boy" and follows his father everywhere that he can. Ethan likes reading books and playing games with his brothers. He is excited about adding a little sister to his family and being a big brother for a change.

The social workers shall discuss with the adoptive parents how to implement age appropriate techniques to communicate to their children about the upcoming adoption. The social worker shall provide any assistance to the family as needed for them to do so.

Mark and Tracy Smith are providing age appropriate preparation to their children of how their lives will change with the addition of the adoptive child/ren.

ADDITIONAL ADULT MEMBER AT HOME

16 Even if there are no additional ADULT member at home, please include this section title, and state: “There are additional ADULT MEMBERS in family” under the title.

This section is in green, because most often there isn’t another family member living in the house hold. If there is, however, the social workers shall follow the exact same procedures as has been done for the adoptive parents. The social worker shall report in the following format, similar to the adoptive parents’ format, about the additional household member.

This additional member shall also do a medical form, and get all clearances, and be asked all questions that the adoptive parents shall be asked. Please let us know if you have any questions about this section, since we know it is not common and we would like to avoid any confusion.

Tracey’s mother has recently moved into the Smith’s home.

I have personally seen Mary Tomas and have personally spoken to her alone. She will be in the Smith’s home for approximately one year. She and her husband are currently separated, but have a good relationship.

She is in good health, which is reflected in the medical report.

When asked, Mary Thomas denied any history as an offender whether in the United States or abroad, any history of substance abuse, mental or emotional health problems or any behavioral issues, she denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. She denied any history of alcohol abuse, controlled substances abuse or other substances impaired her ability to fulfill obligations at work or home or crate other social or interpersonal problems.

She would not hesitate attending counseling if needed due to adoption issues of her daughter. When asked, she denied ever being involved with any prior home studies, ever being the subject of an unfavorable home study or ever being rejected as a prospective adoptive parent ever being a subject of a home study terminated without completion related to any adoption or any form of foster care or other custodial care. This social worker asked Mary Thomas the following direct questions and she replied “no” to each question: 1. Have you ever been denied as prospective adoptive parent or been the subject of an unfavorable home study? 2. Have you ever begun a home study process in relation to an adoption or to any form of foster or other custodian care of a child that was not completed?

In case there was a prior or terminated home study please write the following information: 1. Identify the agency involved in each prior home study;

17 2. When the prior home study process began; the date prior home study was completed; 3. Whether the prior home study recommended for or against finding the additional adult member for suitable for adoption, foster care or other custodial care of a child; 4. If a prior home study was terminated without completion the current home study must indicate when the prior home study began, the date of termination and the reason for the termination; 5. If there was a non favorable prior home study for the additional adult member a copy of it needs to be presented together with this home study.

As I have personally seen Mary and I have spoken with her alone. She is very excited about the prospect of Tracey and Mark adopting a child and sees her role as peripheral, by helping to keep the daily activities in order while Tracey and Mark are able to bond with their child.

If there are any criminal (or other history) for the additional adult member that needs to be disclosed, please use the appropriate sections (above) of this template to accommodate for the given individual.

If someone (18 and above) lives in the same household as the adoptive parents, they must forego EVERYTHING as the adoptive parents themselves.

MARRIAGE

Mark and Tracy were married on June 7, 1995 in Vune, Denmark. This couple met when they were both officers in the United States Army and assigned to the same unit in Germany. Both were immediately attracted to each other and knew soon after meeting they had found their partner for life. Tracy was attracted to Mark’s fun loving nature and easy going personality. She also describes their similar interests and easy compatibility. Mark was attracted to Tracy’s fun-loving nature, honesty, reliability and strong faith.

They have been married for 13 years. They demonstrate a close bond and commitment to each other. During their marriage, Mark has served in Iraq. The time apart has only deepened their commitment to each other and to their marriage. Both demonstrate their ability to handle differences through compromise, open communication and mutual respect for each other’s feelings and opinions. They have great respect for each other and easily recognize their priorities in life as being church and family. This couple has shared values and a belief in God to guide them individually and as a family. They have similar views on parenting and are dedicated to each other. Their marriage has been successful and stable.

In green above, the social worker shall use his/her clinical evaluation to make a statement about the family’s marriage and an evaluation of the stability of the marriage.

18 PREVIOUS MARRIAGES

In this section we need a separate sentence for each of the adoptive parents.

There are no previous marriages for Mark Smith. There are no previous marriages for Tracy Smith.

If there are previous marriages, the social worker shall state the following:

When it began When it was terminated How it was terminated If there are custody agreements, discuss them Discuss alimony

MILITARY HISTORY

Even if there is no military history for the adoptive parents, the social worker shall include this section title, and state:

“There is no military history for Mr. “There is no military history for Mrs.

As previously mentioned, Mark enlisted in the United States Army in 1987 and served as a Medical Service Corps Officer. He was stationed at Fort Bragg, Texas, and Germany. Mark was honorably discharged in 1997. He returned to the United States Army in 2008 as a Commissioned Captain. He currently serves as a Physician Assistant assigned to the 7nd Airborne Division at Spring Ville, North Carolina and has a rank of Captain. He is currently deployed to Iraq until at least December 2008. He plans to remain in the United States Army until retirement.

As previously mentioned Tracy enlisted in the United States Army in January 1991 and served in Germany as a Platoon leader and Company Commander in medical field units. From January 1996 until June 1999, Tracy served in San Antonio, Texas and managed the Army Health Care Provider Scholarship Program. From July 1998 through June 1999, Tracy completed an internship at Evans Army Community Hospital at Fort Carson, Colorado. In July 1999, Tracy became the Chief of the Clinical Services Division at Fort Hua, Arizona. She was honorably discharged from active duty in July 2001. From August 2001 to the time of the writing of this document, Tracy serves in the Army Reserves as a personnel officer. She will retire in January 2009.

There is no previous military history for Mary Thomas. (Additional house hold member)

19 IDEAS ABOUT CHILD REARING AND ADOPTION

Mark and Tracy wish to adopt children of the Caucasian race.

The social worker shall, make a statement – evaluation, about the adoptive parents’ parenting philosophies and their intent of how they will parent the adopted children.

Mark wants to adopt and Tracy wants to adopt. They jointly made the decision to adopt. This is their first experience with adoption other than the support they provided Tracy’s sister when she adopted two children from Liberia. Mark and Tracy Smith believe that the best way to teach children responsibility is to be a good example. They plan to use allowances and age-appropriate chores to teach accountability and responsibility. They plan to reward good behavior and discipline negative behavior as needed by using verbal reprimands, time outs, and loss of privileges. They believe discipline should be consistent, reasonable and directly correlated to the incident. Mark and Tracy will provide many opportunities for their children in regards to education, sports and social activities. They will allow their children to explore their talents and strengths and will encourage them to excel in those areas. They will not use corporal punishment with their children.

The social worker shall explain that corporal punishment is not acceptable. If needed, the social worker should provide the adoptive parents on parenting techniques which do not include corporal punishment.

The following section is again underlined to be brought up to the social worker’s attention. The social worker shall make a statement-evaluation on the following:

Mark and Tracy, each of them is emotionally stable and mature to be an adoptive parent.

Mark and Tracy, each of them has a strong ability to cope with problems, stress, frustrations, crisis and loss.

Mark and Tracy, each of them has a good ability to give and receive affection.

Mark and Tracy, each of them has strong child caring skills and willingness to acquire additional skills needed for the children’s development.

Mark and Tracy, each of them has a good ability to provide for the children’s physical and emotional needs.

Mark and Tracy are aware of the importance of the children knowing as much about their background and heritage as possible. They also recognize the importance of children having knowledge of the fact that they were adopted from the very beginning of their relationship. They have very supportive families and friends who know that they are involved in the process of adoption. They are very excited about the prospect of becoming adoptive parents and are committed to the adoption alternative.

20 Mark and Tracy Smith state that they will encourage their adopted children to learn more about their Bulgarian /European heritage. They will make opportunities available to continually educate themselves and their children concerning the Bulgaria and its strong history. Mark and Tracy state they plan to return to the Bulgaria to show their children their homeland and assist them in gaining personal and deep appreciation for the land, people, and deep rooted heritage.

Their goals for their child are to always have their basic needs met and encourage the child to learn and grow to their highest potential. They want the child to be happy and they will support the child as they grow and help to pursue their interests. They will expose them to different activities and they can discover what they like best. Education is significant to both Mark and Tracy, and they plan on staying involved in their school and encourage a college education.

The social worker shall ask each of the parents their thoughts/feelings about the biological parents and make a separate statement for each of them.

Tracy said she recognizes and admires the birth parents’ strength and love for their child that led them to make the choice to give their child a better chance in life and she said she can only imagine what a hard decision it would be to give up their child.

Mark said he understands the birth parents made a very difficult and courageous decision and understands they made the decision out of love for their child. He appreciates the birth parents for allowing their child to be adopted and he feels fortunate that they gave their child for adoption.

The social workers shall discuss with the adoptive parents what will happen in case of unexpected death. The social worker shall work with the parents to help them put a plan in place. Appointees must not be significantly older than the adoptive parents such as the adoptive parents’ parents (the child’s grandparents). Preferably a sibling of either adoptive parent may be considered a good choice.

Childcare plans at this time are for Tracy to stay home with the children for at least three months with the exact time out of work being dependent on the needs of the children. Tracy is planning to return to work part time and their children will attend daycare either at base at Fort Bragg or in a private school. When Tracy returns to work full time, the child will be in daycare 6-8 hours per day, 5 days per week. She also is making plans to adjust her work schedule to allow her to work at home during the day, significantly reducing the amount of time their children will attend daycare. Both Mark’s and Tracy’s parents plan to visit frequently and assist with childcare. In the event of unexpected death, Mark and Tracy have decided to appoint Mark’s sister Mary and her husband Hugh Thurman, as Legal Guardians. They are planning to have a Last Will and Testament completed by the time the adoption is completed.

21 The following section below address again the adoptive parents’ preparedness about the upcoming international adoption. The social workers shall implement clinical skills to counsel the adoptive parents as needed, answer any questions they may have on these topics. The social worker may chose to provide additional resources for the parents in order to further their education and preparation. The social worker may consult with our agency’s social worker supervisor in order to devise potential strategy designed for the particular family’s preparation. The social worker shall rephrase this section, if necessary to accommodate for the parents’ capabilities based on his/her clinical evaluation and describe the conditions that the family will be willing to accept and the social worker will give his/her clinical approval.

Mark and Tracy are willing to accept a child with special needs without any specific restrictions on case by case basis. Mark and Tracy were counseled on the complexity of international adoption and are fully aware of all possible outcomes including delays, processing, expenses, and difficulties associated with international adoption. The counseling included a discussion of the processing, expenses, travel, difficulties and delays associated with international adoptions. Mark and Tracy are also aware the child they adopt might develop or have an undiagnosed medical or psychological condition(s) following or prior to adoption. Mark and Tracy accept this possibility and are willing to take this risk. Mark and Tracy are also aware of development, malnourishment, fetal alcohol and attachment issues related to the adoption of a child from an institutional or foster care setting. They will assume full responsibility for the medical and financial needs of their adopted child upon adoption finalization and will cooperate with a licensed agency in its provision of post placement services.

Your agency’s name here……. has provided the prospective adoptive parents Mark and Tracy information about print, internet, and other resources available for continuing to acquire information about common behavioral, specific medical, and other issues; connecting with parent support groups, adoption clinics and experts; and their pediatrician, Dr. ………… at Pediatric………….., is available for them to provide medical advise appropriate to the children’s special needs if any.

Saint Mary International Adoption will assure that such training will be accomplished before Mark and Tracy travel to Bulgaria to adopt the children. The certificates of accomplishment of the training will remain in agency’s office as part of the adoptive parents’ file.

Please select one of the following paragraphs “exempt provider” or “supervised provider” as it applies to your agency. In most cases, the “exempt provider” applies to the agencies that we work with.

FOR EXEMPT PROVIDERS PLEASE WRITE:

Post adoption counseling will be conducted at appropriate intervals by a your social worker title licensed social worker who is an employee of your agency’s name and supervised by Saint Mary International Adoptions’ Masters level social worker at

22 appropriate intervals who is an employee of Saint Mary International Adoptions following Code of Federal Regulations, your state adoption Code, North Carolina Administrative Code, and 22 CFR Part 96.48 and agencies’ Policies and Procedures.

Post placement counseling will be conducted by Saint Mary International Adoptions’ Masters level social worker at appropriate intervals who is an employee of Saint Mary International Adoptions according to 22 CFR Part 96.48 and agency’s Policies and Procedures.

FOR SUPERVISED PROVIDERS PLEASE WRITE

Post placement and post adoption counseling will be conducted by your agency name agency’s licensed social worker who is an employee of your agency name and supervised by Saint Mary International Adoptions’ Masters level social worker at appropriate intervals who is an employee of Saint Mary International Adoptions following Code of Federal Regulations, your state adoption Code, North Carolina Administrative Code and 22 CFR Part 96.48 and agencies’ Policies and Procedures.

PREPARATION FOR ADOPTION

The social workers shall be reminded that the adoptive parents must take the adoption preparation course which is describe below.

In addition to the counseling provided by this social worker, Mark and Tracy are attending 10 hours of adoption preparation and training designed to promote a successful international adoption as it is set forth in 22 CFR Part 96.48. The on-line training through Adoption Education, LLC which include; Attachment and Bonding, Behavioral and Mental Disorders, Culture and Identity, Effects of Institutionalization, Effects of Stress in Early Life, Fetal Alcohol Syndrome, Malnutrition, Prenatal Exposure to Drugs and Maternal Smoking, Sensory Integration Disorder, Special Regional Considerations, Travel and Transition.

If your agency provided any additional training please describe it here in detail. If during the process of the home study, the social worker decided to provide additional resources and/or training the social worker shall describe this training here.

They have received a certificate of completion that will be maintained in the family’s permanent file. Mark and Tracy shared with this worker their understanding of how they would access services for the needs of their child; it is this worker’s observation that they are aware of how to access professional services for a child who may have special needs. Under 22CFR 96.48, the family has received appropriate adoption education for the

23 purpose of this home study and will continue to receive ongoing education and support from their home study and placing agency as needed; through classes, counseling; online resources; or referrals to appropriate professionals. Post-Placement monitoring will be provided to Mark and Tracy in accordance with 22 CFR 96.50.

The following language is consistent with the adoption education courses. The social worker shall discuss with the family, the family’s thoughts and understanding of the information provided in the preparation course. The social worker shall then consider the language below, discuss it with the family, and decide if anything needs to be changed, and or added, so to reflect the family’s situation.

Both Mark and Tracy reported they will continue to seek training regarding any specific issues this child has or may develop throughout the years. They both feel comfortable in reaching out and seeking community resources when needed. Both Mark and Tracy reported they will treat any adopted child as they would a biological child in all aspects. They reported they understand the purpose and permanency of adoption. It is the opinion of this caseworker that Mark and Tracy have met the all preparation requirements and have adequately prepared for this adoption.

Underlined above, is underlined to attract the social worker’s attention to an opinion expressed in the template that is liable to change per the social worker’s clinical evaluation.

HEALTH

A “health” section is required of course. Our agency has provided the adoptive parents a medical form which they were to take to their physicians in order to get a medical evaluation of each parent. The paragraph below summarizes the questions asked on the form. Some of these may not be very familiar to US standards, but they are desired by Bulgarian authorities. The social worker shall ask the adoptive parents for this form this section is being reported.

Mark Smith received medical evaluations on May 14, 2015. He is reported to be in excellent health. He does not take any medication at this time. He has not had any surgeries or hospitalizations. Tuberculosis test was negative. Dermatologist exam was negative. He does not have any mental disorders or emotional health problems or any behavioral issues. He does not have any lung diseases. He does not have any sexually transmitted diseases. Hepatitis test was negative. AIDS test was negative. Wassermann test was negative. Mark does not have any addiction to alcohol or drugs. No referrals to mental health professionals were made.

24 The social worker shall provide a clinical opinion of each adoptive parent:

It is this social worker assessment that Mark is emotionally, physically and mentally stable and will provide a loving home for a child.

Tracy Smith received a medical evaluation on July 5, 2015. She is reported to be in excellent health. She does not take any medication at this time. She has not had any surgeries or hospitalizations. Tuberculosis test was negative. Dermatologist exam was negative. She does not have any mental disorders or emotional health problems or any behavioral issues. She does not have any lung diseases. She does not have any sexually transmitted diseases. Hepatitis test was negative. AIDS test was negative. Wassermann test was negative. Tracy, however, has endometriosis and she is unable to conceive children. This condition does not cause any other medical issues for Tracy. Tracy does not have any addiction to alcohol or drugs. No referrals to mental health professionals were made.

Dr. Kelly recommended Mark and as Tracy adoptive parents.

It is this social worker assessment that Tracey is emotionally, physically and mentally stable and will provide a loving home for a child.

If there are children in the family, the social worker shall include them in this section as well. A recent evaluation from their pediatrician is needed. The children use the same form which we’ve provided to the parents. However, many of the “conditions” that are to be checked by the doctor will not be applicable for the children. It is therefore, okay for their pediatrician to check “NA” where applicable. Their medical exam should be an age appropriate annual physical.

Emily Smith is also in excellent health. Her pediatrician has seen her regularly. She is current with all immunizations. Her medical evaluation was received on July 16, 2015.

Lauren Smith is in excellent, health. Her pediatrician has also seen her regularly. She is current with all immunizations. Her medical evaluation was received on July 16, 2015.

If there is an adult 18 years or older (such as an additional household member) the social worker shall include the additional person’s medical evaluation which shall be the same as the adoptive parents’ evaluation using the same medical form provided.

Mary Smith received a medical evaluation on September 14, 2015. She is reported to be in excellent health. She does not take any medication at this time. Tuberculosis test was negative. Dermatologist exam was negative. She does not have any mental disorders or emotional health problems or any behavioral issues. She does not have any lung diseases. She does not have any sexually transmitted diseases. Hepatitis test was negative. AIDS test was negative. Wassermann test was negative. She does not have any addiction to alcohol or drugs. No referrals to mental health professionals were made.

25 LIFESTYLE

Mark and Tracy lead very active and involved lifestyles. They enjoy spending time involved with family and church related activities. Both Mark and Tracy enjoy running, golfing, skiing, cycling, and attending sporting events together. They also enjoy attending community events and visiting museums. They take pleasure in spending time with each other at home. They also enjoy spending time with friends and family.

RELIGION

Mark and Tracy describe their faith in God as their strongest bond. They are both active in church and rely on their faith when making decisions. Mark and Tracy attend Catholic mass at St. Patrick’s Catholic Church in Fayetteville, NC on Saturday night and attend Christian non-denominational services on Sunday. They participate in Catholic bible studies and have taught Sunday school at a Christian non-denominational church. Both recognize the importance of their faith in God in their daily lives. They report looking to God for guidance and inspiration through prayer, reading the bible, and attending church. Tracy also participates in a wife’s bible study group and is currently reading “The Power of a Praying Wife”. Mark is a member of the Christian Medical Association and the Archdiocese of Washington. Mark and Tracy plan to raise their children in church and will pass their strong faith in God on to their children. Both report their church family is supportive of their decision to adopt and are eager to assist them with any needs.

HOME AND COMMUNITY

Mark and Tracy reside in the beautiful and well-established neighborhood of Anderson Creek Club in Spring Lake, North Carolina. Their address is 16 Pine Lane, Spring Ville, NC 28530. The private gated community consists of several houses, hiking trails, golf courses, fishing ponds, a clubhouse with fitness room, sheltered picnic areas, waterfalls, canoeing and paddleboats, tennis courts, swimming pool and spa, basketball court, bocce court, shuffleboard, recreation field, and a croquet course. Every home is very attractive and has well-maintained yards. There are several young families with children in the neighborhood. The community is convenient to good schools, shopping and medical services, local fire and police departments, major roadways and recreational and cultural activities.

The home is an attractive two story house with a 2-car garage. The value of this house at the time of purchase was $301,500. The house is currently valued at $301,500. Upon entering the home there is a small foyer. On the right is a formal dining room. Next on the right is a kitchen with pantry. By continuing straight, you enter a small eating area and a large den. Beyond the den is a large screened-in porch. To the left of the den are a half bath and a closet. Also to the left of the den is the master bedroom and master bathroom with 2 closets. Outside the master bedroom is the stairway leading to the

26 second floor of the home. To the left of the top of the stairs is a bonus room that will be converted to a play room for the children. Turning to the right at the top of the stairs leads to a hallway. The first room on the upstairs hallway is an exercise room. Continuing down the hallway leads to a full bathroom and 2 more bedrooms. Both large bedrooms are fully furnished and have walk-in closets. Each level of the home is fully equipped with smoke alarms, carbon monoxide detectors and fire extinguishers. Mark and Tracy plan for each of their children to have their own bedroom upstairs and they will share the upstairs bathroom.

The social worker shall make a statement-evaluation of the safety of the home and conclude whether it’s a safe place to raise children, and how many children could be accommodated.

I find this home suitable to accommodate comfortably up to two children. This home exceeds the state requirements for safe and suitable accommodations for a child.

The home is more than adequately furnished and is attractive throughout with a traditional and neutral motif. The housekeeping standards are immaculate. Mark and Tracy have lived in this house for one month at the time of the writing of this document.

The following statement basically just says how their home is being financed and by what bank:

The Statement from the financial institution, Bank of America showing the itemization of the mortgage has been seen.

EMPLOYMENT

Mark is employed by the United States Army as a Physician Assistant. He enjoys his work and believes his position affords him job stability and the ability to provide well for his family.

Tracy is employed by Mercy Hospital as a Health System Specialist. She also greatly enjoys her work and feels fortunate to also have job stability and the ability to provide well for her family. She plans to stay home with the children for at least three months, dependent upon the children’s needs before returning to work full time. Upon returning to work, Tracy intends to work an alternative schedule that will allow her to work form home several hours per week.

FINANCES

The social worker shall review the family’s most recent tax return, W2, 1099, banks statements, other financial statements to evaluate their ability to provide for a child or

27 children. The numbers, as they apply to each adoptive parent, should be disclosed in this section.

Mark and Tracy Smith earn an approximate, joint gross income of $132,809 as it is shown in their U.S. Joint Income Tax Return Form for 2014.

Mark’s annual salary includes approximately $20,000 of non-taxable income; this amount is not included in the U.S. Individual Income Tax Return Form for 2014. Therefore the full income for 2012 is $152,809.

Mark Smith currently receives an annual salary of $81,566 as an employee of the United States Army. Tracy Smith currently receives an annual salary of $70,949 as a civil service employee of Womack Army Medical Center.

In this section is important to consider all financials (if applicable) including:  health and dental insurance  life insurance,  automobile insuranc  retirement plans  saving account  checking accounts  mortgage  etc…

The social worker shall make a statement that he/she has seen a copy of each account described and name the financial institution.

Mark and Tracy have full medical and dental insurance and benefits coverage through the United State Army. A form completed by Mark’s employer verifying insurance benefits has been seen. The adopted children will be covered by the family’s insurance upon adoption and enrollment by Mark and Tracy. Both Mark and Tracy also have life insurance through Soldier Group Life Insurance. Mark’s life insurance coverage is in the amount of $400,000. Tracy’s life insurance coverage is in the amount of $400,000. Statement from the life insurance company has been seen.

Mark and Tracy do have insurance coverage of their automobiles with United Services Automobile Association. They also have homeowners insurance through United Service Automobile Association. Statements from the insurance company verifying coverage have been seen.

Mark Smith has an active duty retirement plan through his employer in the amount of $3,579 per month upon retirement. Tracy Smith has a civil service retirement plan in the amount of $2,509 per month upon retirement and an Army Reserves retirement plan in

28 the amount of $2,485 per month upon retirement. In addition, Tracy Smith has a 401K retirement plan in the amount of $3,713 per month upon retirement.

Mark and Tracy have shared checking and savings accounts with Bank of America. Their checking account has a balance of approximately $24,064. Their savings account has a balance of approximately $19,960. Account Statements from Bank of America were provided.

The current debts of Mark and Tracy Smith include the balance of the house mortgage at approximately $300,000 with a monthly payment of $1,916.22. A statement for the loan from National Bank of Kansas City was provided. They have a revolving credit line account at Citibank with a current balance of approximately $2,010 and a monthly payment of $145.00.

The other monthly expenses are approximately: Electricity - $30; Television Cable and high speed internet - $135; Water/Sewer - $20; Phone- $50; Groceries - $300; Gas - $200

The social worker, after evaluating the financial statements shall make a determination whether she/he approves the family to provide for an adopted child/Ren.

Mark and Tracy Smith are more than able to meet their monthly expenses and will be able to financially support children. The provided financial information establishes Mark and Tracy Smith’s ability to meet the financial needs of adoption.

CRIMINAL HISTORY

Please write separate statements for husband and wife as shown below:

There is no criminal history for Tracy Smith. The criminal record check conducted by the Federal Bureau of Investigation on June 28, 2015 has been seen.

There is no criminal history for Mark Smith. The criminal record check conducted by the Federal Bureau of Investigation on June 28, 2015 has been seen.

It is important that the social worker asks the following questions of each adoptive parent and report their answers separately in this section:

This social worker asked Mark and Tracey Smith the following direct questions and each of them individually replied “no” to each question:

1. Have you ever been arrested or convicted, whether in the United States or abroad?

29 2. Do you have a history of child abuse, sexual abuse, or domestic violence, whether in the United States or abroad? 3. Do you have a history of alcohol, drug or substance abuse, whether in the United States or abroad?

Please be reminded to include any additional household members, 18 and over here as well if applicable.

There is no criminal history for Mary Thomas. The criminal record check conducted by the Federal Bureau of Investigation on June 28, 2015 has been seen.

This social worker asked Mary Thomas the following direct questions and she replied “no” to each question:

1. Have you ever been arrested or convicted, whether in the United States or abroad? 2. Do you have a history of child abuse, sexual abuse, or domestic violence, whether in the United States or abroad? 3. Do you have a history of alcohol, drug or substance abuse, whether in the United States or abroad?

If there are not other adult members in the household:

There are no other adult members of the household.

CHILD ABUSE HISTORY

The social worker shall check the adoptive parents’ (and any additional adult household member’s) child abuse registries for any state or foreign country that each of them has resided in since that person’s 18th birthday!

The North Carolina child abuse applies only to NC social workers.

The State of North Carolina, Department of Health and Human Services does maintain a child abuse clearance system through the Responsible Individual List, authorized by N.C.G.S. 7B-311 and 10A N.C.A.C. 70A.0102. The Responsible Individual List identifies individuals found to be responsible for the abuse or serious neglect of a juvenile. Information from the Responsible Individual List is available to certain authorized users for the purpose of determining current or prospective employability or fitness to care for or adopt children.

Saint Mary International Adoptions has submitted the required form DSS-5268 to the North Carolina Department of Health and Human Services. As of July 19, 2015 Mark Smith’s name was not found on the Responsible Individual List.

30 Saint Mary International Adoptions has submitted the required form DSS-5268 to the North Carolina Department of Health and Human Services. As of July 19, 2015 Tracy Smith’s name was not found on the Responsible Individual List.

The social worker shall do separate statement for each adoptive parent and if applicable additional household member about each and every state or foreign country in which they’ve resided in since their 18th birthday. All other states please write separate statements for husband and wife as shown below:

Mark Smith stated that has been resided in the following states: Michigan, New York, Virginia and North Carolina since his 18th birthday.

Mark Smith was cleared by the State of Michigan for any history of child abuse or history with child protection services on July 21, 2015.

Mark Smith was cleared by the State of New York for any history of child abuse or history with child protection services on July 25, 2015.

Mark Smith was cleared by the State of Virginia for any history of child abuse or history with child protection services on July 28, 2015.

Tracy Smith stated that has been resided in the states: Michigan, New York, Virginia and North Carolina since his 18th birthday.

Tracy Smith was cleared on July 21, 2015 by the State of Michigan for any history of child abuse with child protection services under either her maiden or married name.

Tracy Smith was cleared on July 25, 2015 by the State of New York for any history of child abuse with child protection services under either her maiden or married name.

Tracy Smith was cleared on July 28, 2015 by the State of Virginia for any history of child abuse with child protection services under either her maiden or married name.

The social worker shall ask each adoptive parent (and additional house hold member) separately the following direct questions. Each adoptive parent shall have a separate paragraph indicating their answers.

When asked, Mark Smith denied any history as an offender whether in the United States or abroad. He denied any history of substance abuse, mental or emotional health problems or any behavioral issues. He denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. Mark Smith denied ever been a respondent in a domestic violence proceeding or a proceeding concerning a minor who was allegedly abused, neglected, dependent, undisciplined or delinquent, and the outcome of the proceeding. Mark Smith denied ever been found to have abused or neglected a child or has been a respondent in a

31 juvenile court proceeding that resulted in the removal of a child or has had child protective services involvement that resulted in the removal of a child. He denied ever been arrested neither convicted of crime other than a minor traffic violation and the DUI discussed earlier in this document.

When asked, Tracy Smith denied any history as an offender whether in the United States or abroad. She denied any history of substance abuse, mental or emotional health problems or any behavioral issues. She denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. Tracy Smith denied ever been a respondent in a domestic violence proceeding or a proceeding concerning a minor who was allegedly abused, neglected, dependent, undisciplined or delinquent, and the outcome of the proceeding. Tracy Smith denied ever been found to have abused or neglected a child or has been a respondent in a juvenile court proceeding that resulted in the removal of a child or has had child protective services involvement that resulted in the removal of a child. She denied ever being arrested neither convicted of a crime other than a minor traffic violation.

When asked, Mary Thomas denied any history as an offender whether in the United States or abroad. She denied any history of substance abuse, mental or emotional health problems or any behavioral issues, she denied any history of sexual abuse, child abuse, or domestic violence even if it did not result in an arrest or conviction. Mary Thomas denied ever been a respondent in a domestic violence proceeding or a proceeding concerning a minor who was allegedly abused, neglected, dependent, undisciplined or delinquent, and the outcome of the proceeding. Mary Thomas denied ever been found to have abused or neglected a child or has been a respondent in a juvenile court proceeding that resulted in the removal of a child or has had child protective services involvement that resulted in the removal of a child. She denied ever being arrested neither convicted of a crime other than a minor traffic violation.

This social worker advised the adoptive parents Mark and Tracy Smith and Mary Thomas during both joint interviews and during each separate interview of their duty to disclose true and complete information as set forth in 8 CFR 204.311(d) relevant to the proper completion of the home study. Each of the prospective adoptive parents (and the additional household member) expressed their understanding that they must answer all questions truthfully and completely and that they must disclose each and every arrest or conviction, or other adverse criminal history, whether in the United States or abroad even if the record has been erased, dismissed, expunged or ameliorated in any other way; and disclose any other relevant information, such as physical, mental or emotional health issues or behavioral issues. Mark and Tracy Smith and the additional household member Mary Thomas each of them indicated their understanding that the duty of candor is an ongoing duty regarding any new event or information that might warrant submission of an amended or updated home study until the final decision admitting the Convention adoptee to the United States. This social worker informed the adoptive parents Mark and Tracy Smith and the additional household member Mary Thomas about the consequences in case they fail to disclose any information for questions that they have been asked. This

32 social worker also advised Mark and Tracy Smith and Mary Thomas and they expressed their understanding of 8CFR 204.311(c)(13) and (14) and 204.311(j) concerning history of substance abuse, sexual abuse, child abuse, or family violence. In particular, they understand that a single incident of sexual abuse, child abuse or a family violence is sufficient to constitute a “history”.

If there is not another adult please write the sentence:

There are no other adult members of the household.

REFERENCES

References cannot be blood relatives

Mark and Tracy Smith received three excellent letters of references. All were much in favor of the couple’s decision to adopt and believe that they have the capacity to provide an environment of love, faith, and stability for adoptive children. All of these positive reference letters have been seen and a list of the references with phone numbers is attached.

RECOMMENDATION

Mark and Tracy Smith are strongly committed to one another as well as in their desire to build and extend their family through international adoption. This is the first pre- placement assessment ever completed or done for this couple.

They prove financial and emotional stability and I believe they are ready to share these strengths with adopted children. Mark and Tracy have a loving home environment and they are prepared to pursue the adoption alternative and extend their family with a great deal of thought, education and planning. They are supported in this decision by family members and friends. They have met the home study requirements according to 22 Code of Federal Regulations Part 96.47 and 8 Code of Federal Regulations Part 204.311 and all of the state requirements as well as the specific requirements for the Convention country of Bulgaria.

Upon conclusion of the evaluation of the each adoptive parent and both of them as a family, the social worker shall make a recommendation, one way or the other, about their suitability to become adoptive parents. This is required by law.

My approval is that Mark and Tracy Smith are excellent candidates for adoption. Therefore, it is strongly recommended that placement be allowed for up to two Convention adoptees to be placed for adoption with them. These Convention adoptees will be from the Convention country of Bulgaria. These Convention adoptees will not be older than four years of age. The sex will be either male or female. These Convention

33 adoptees will be healthy or with special needs without any specific restrictions on case by case basis.

My approval is that Mark and Tracy Smith are prepared to meet the needs of special needs children, without any specific restrictions on case by case bases. Mark and Tracy Smith have obtained all training and counseling needed as well as print, internet, and other resources available for continuing to acquire information about common behavioral, specific medical, and other issues; connecting with parent support groups, adoption clinics and experts; and their pediatrician Dr ……… at ……………… is available for them to provide medical advise appropriate for children’s special needs if any.

This pre-placement has been conducted by LSW Social Worker ……… duly licensed and certified under the State of ……… to conduct pre-placement assessment for adoptive parents with license number….. who is an employee of …………. Agency with your state license #...... issued by………expires on……. .

(Your agency name)………..agency is a home study preparer as defined under 8 Code of Federal Regulations 204.301 as an Exempt Provider to conduct this home study.

This home study will be further reviewed and approved by Saint Mary International Adoptions which is a Hague Accredited agency authorized under 22 Code of Federal Regulations, Part 96 as a child placement agency to conduct Convention home studies and Convention adoption placements.

This Home Study meets all the requirements of your state home study requirements (precise section number) and North Carolina 10.A N.C.A.C.70H. 0405 and Title 8 Code of Federal Regulations, Part 204.311 and Title 22 Code of Federal Regulations, Part 96.47.

This Home Study has been provided in five copies, each of which is a true and accurate copy of the Home Study that was provided to the prospective adoptive parents.

Submitted by: ______LSW

Approved by: ______MSW

ADOPTION HOME ASSESSMENT

This is the adoption home study of Mark and Tracy Smith.

34 This adoption home study was completed for your agency’s name a licensed ……… agency in the State of ……………… (license number ………issued by…….expires on……).

I, ……… SW, certify under penalty of perjury under US law that:

1. This adoption home study was completed by me with the professional diligence reasonably necessary to protect the best interests of any child(ren) whom these adoptive parents might adopt. 2. The factual statements in the home study are true and correct, to the best of my knowledge, information and belief; and 3. I personally have advised the applicants of their duty of candor under 8CFR 204.311(d) and to provide true and complete information only and of their ongoing duty under 8CFR 204.311(d) (2) concerning disclosure of new events of information.

Submitted by: ______SW

Approved by: ______MSW

State of ______County of ______

I, ______A Notary Public for said County and State, do hereby certify that

______personally appeared before me this day and acknowledged the due execution of the foregoing instrument.

Witness my hand and official seal, this day ______month ______, year______.

…………………… ______(Official seal) Signature of Notary Public

My Commission Expires: day ______, month______, year______.

LIST OF SUPPORTIVE DOCUMENTS

1. Birth Certificate for Mark Joseph Smith (State of Maryland). 2. Birth Certificate for Tracy Frances Coyle (Smith) (State of Wisconsin). 3. Marriage Certificate for Mark and Tracy Smith (Denmark).

35 4. Divorce decree(s) if applicable – all of them for each, husband and wife. 5. Mortgage Statement from Bank of America. 6. U.S. Individual Income Tax Return Form 1040 filed jointly for Mark and Tracy for 2014. 7. Statement from United Services Automobile Association regarding the automobile insurance policies for both Mark and Tracy. 8. Statement from United Service Automobile Association regarding homeowner’s insurance policy 9. Employment letter for Mark Smith from the Department of the Army. 10. Employment letter for Tracy Smith from Department of the Army, Mercy Hospital. 11. Statement from Bank of America regarding checking account for Mark and Tracy Smith. 12. Statement from Bank of America regarding savings accounts for Mark and Tracy Smith. 13. Statement from CitiBank regarding revolving credit line for Mark Smith. 14. Medical Information Form for Mark Smith from Womack Army Medical Center, Fort Bragg, NC. 15. Medical Information Form for Tracy Smith from July 5, 2015. 16. Three letters of reference for Mark and Tracy Smith. 17. Letter from the FBI regarding Mark Smith. 18. Letter from the FBI regarding Tracy Smith. 19. Final Disposition regarding DUI for Mark Smith (Chatham County, Georgia). 20. Certificate of Completion for DUI Program for Mark Smith (Georgia Department of Human Resources). 21. Medical insurance letter for Mark and Tracy Smith. 22. Request for Information from the North Carolina Responsible Individuals List for Mark Smith (North Carolina Division of Social Services). 23. Request for Information from the North Carolina Responsible Individuals List for Tracy Smith (North Carolina Division of Social Services).

36 24. Child abuse clearances for Mark Smith: please make a separate statement for each child abuse clearance. 25. Child abuse clearances for Tracy Smith: please make a separate statement for each child abuse clearance

LIST OF REFERENCES

1. Bryan and Elisabeth Goff 31 Northwest Drive Silver, MD 20922 Phone: 301-666-5371

2. Susan Jackson 379 Florida Street Los Angeles, CA 92122 Phone: 619-097-4756

3. Deanna Miller 98 Grayson Road Silver, MD 20954 Phone: 204-421-2366