Grant Application

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Marital Status

Name of Spouse (if applicable)

First Name

Last Name

Spouse Date of Birth

YYYY

Spouse Email (If Applicable)

Spouse Phone (If Applicable)

(###)

###

####

Names and Ages of all Biological Children

Names and Ages of all Adopted Children

Employer Name and Position

Annual Salary

Spouse Employer Name and Position (if applicable)

Spouse Annual Salary

Home Study Completion Date

YYYY

Adoption Agency Name

Agency Phone

(###)

###

####

Agency Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Case Worker's Name

First Name

Last Name

Case Worker's Phone

(###)

###

####

Case Worker's Email

Adoptee's Country of Origin?

Number of Children Adopting?

Adoptee's Name and Age

If referral, describe any special needs

Expected Placement Date

YYYY

Financial Overview

Combined Adjusted Gross income

Annual Charitable Giving

List Annual Expenses

Including: Mortgage/Rent, Utilities, Groceries, Transportation, Phones, Education, Debt, Taxes, Medical, Daycare, Recreation, Other. List each expense individually and then add up your total annual expenses.

Net Worth

Please list balances below for the following: cash, checking and savings account, Money Market, Stocks, Bonds Mutual Funds, IRA's, Home Value, Auto's, Possessions, etc. List in each category and then total at the end.

Debt

Please list any debt you have for the full amount to pay off the debt. Including mortgage, auto, student loan, etc. List individually and then total at the end.

What is the total cost of your adoption?

What is your personal contribution?

Have you raised any funds or do you plan to?

Have you received any other grants? If yes, list how much below.

What led you to decide to adopt?

What do you think will be your biggest strengths and weaknesses as an adoptive parent.

How are you preparing yourself for this change in your family?

Are there any areas you feel like you could use guidance or support in the adoption journey?

Are you willing to share your story and family photo with One Less when the adoption is complete?

Consent

By checking this box I am approving my electronic signature and stating that everything written in this form is truthful and accurate to the best of my knowledge.

Yes

Name

First Name

Last Name

Spouse Name (if applicable)

First Name

Last Name

Date of Application Signature

YYYY