Adoption by Shepherd Care PROFESSIONAL ADOPTION SERVICES Corporate Office: 5935 Taft Street, Hollywood, FL. 33021 Phone: 954 981 2060 Fax: 954 981 2117 adopt@adoptabsc.org www.adoptabsc.org This is an exciting time to begin the adoption process with Adoption by Shepherd Care, and our experienced staff will walk you carefully through every step of your adoption journey. At Adoption by Shepherd Care, we understand that Canadian families researching adoption from the United States have many questions, and we hope that in this information packet you will find not only answers to your questions, but also hope for the future of your family. While many U.S. agencies have closed their programs to Canadian families after the implementation of the Hague Convention in the U.S., Adoption by Shepherd Care has remained committed to serving Canadian families who are seeking to adopt. We have worked closely with the U.S. Department of State and Canadian provincial governments to establish processes that are in compliance with the Hague Convention, and we have successfully completed numerous Hague adoptions into Canada with possibilities for more each day. We continue to offer our services to families residing in British Columbia, Alberta, Saskatchewan, and Manitoba, and we are actively investigating the possibilities of working with families in other provinces as well. Adoption by Shepherd Care (ASC) was founded in 1980 and has been operating as a licensed childplacing agency in the State of Florida since that time. ASC is a 501 (c)(3) non profit agency and is accredited by the Hague Convention and the Council on Accreditation. ASC works with courageous birthmothers who are making an adoption plan for their child and loving couples who seek to become parents through adoption. Couples must have been married for at least one year, and their average age must be between 25 and 50 years with neither spouse s age exceeding 52 years. In order to continue to maintain the average wait time for families that are currently registered with our agency, ASC limits the number of families that can be actively registered in our program at any given time. When a family has submitted a complete dossier with ASC they may be placed on a wait list until space becomes available in the program. From the time of registration in the program, couples may anticipate being matched to a birthmother within an average of 9 to 18 months. Couples create a profile of their family, and birthmothers select a family for their child after viewing profiles of waiting families. Most couples will be matched with birthmothers who are at least four months or more into their pregnancy, and some couples are chosen by birthmothers who have recently given birth or who are parenting an older child.
We work with birthmothers who are in a variety of situations some are receiving prenatal care while others are not, some are working to care for themselves physically while others are struggling with recreational substance use or addictions, some are making an adoption plan for their unborn child while others are making an adoption plan for the three month old they have been parenting. During the registration process, adoptive families have the opportunity to convey to ASC staff what types of situations they are open to, and their profiles will be shown only to birthmothers whose situations match with the family s comfort levels. ASC supports a philosophy of semi open adoption, which usually involves a meeting between the birthmother and adoptive family and the exchange of pictures and letters through the years. The meeting typically takes place after the birth of the child when the family travels to Florida. The family is then responsible for sending pictures and letters to the birthmother through ASC, at regular intervals during the child s first two years of life and then once yearly until the child is eighteen years old. In some cases, the family and birthmother choose to have more open communication. Even in difficult economic times, ASC strives to keep the cost of adoption as low as possible without compromising our comprehensive services to adoptive families and birthmothers. The average costs of adoption through ASC includes all agency fees, assistance to the birthmother, and legal fees. The average costs in US dollars are as follows: $35,000 $40,000 for the adoption of a Caucasian or Hispanic child; $31,000 $34,000 for the adoption of a biracial child; and $25,000 $30,000 for the adoption of a full black/african American child. ASC subsidizes the costs of black/african American and biracial adoptions as most families who adopt these children reside a significant distance from ASC offices and therefore incur additional expenses from their home study agency and from travel costs. When a family is selected by a birthmother, an escrow payment between $5,000 and $7,000 is due. The family is then invoiced monthly during the pregnancy, and may be asked to replenish escrow funds used in the birthmother s case. The balance of placement fees are due at the time of placement, after the birth of the child. According to Florida law, a birthmother may sign consents to adoption 48 hours after the birth of the child or upon the birthmother s discharge from the hospital whichever is sooner. There is no revocation period in the state of Florida for children under six months of age, and a birthparent can revoke their consent only by proving fraud or duress in court proceedings. Birthfathers may sign papers consenting to the adoption at any time before or after the baby is born. When a family is matched to a case, the details of the birthfather legal situation will be explained to them. After the signing of consents, ASC initiates a series of steps that are required to fulfill the Hague Convention requirements and to allow the adoptive family to take placement of the child and return to Canada. An emergency hearing will be scheduled with a local judge to approve the placement of
the child with a family who resides outside of the United States. This hearing typically occurs about 7 to 10 days after consents are signed, during which time the child will be cared for in an interim care home. Once the order is signed by the judge, the family may take placement of the child. Hotel and airport information will be provided to families to assist them in making travel arrangements. During this time, ASC will provide information on the case to the adoptive family s agency in Canada and/or the provincial government as required by the Hague Convention. If the information on the case is satisfactory to the government, the provincial government will issue official letters indicating their approval of the adoption. When all required documents are received by ASC, the family may return to Canada with their child. Families should be prepared to stay in the United States for as long as necessary to obtain government approval, which may take more than one week after placement. Once home, the adoptive family is responsible for completing three post placement reports through their agency in Canada during the 90 days after the placement of the child in their home. The finalization hearing will be conducted in a Florida court, and the adoptive family may be present at the hearing by telephone in the presence of a notary. The finalization usually takes place about five to six months after the placement of the child in the home. After the finalization, a new birth certificate will be issued with the child s adopted name and the adoptive parents names. Our attorney will then apply for a Hague Adoption Certificate, which certifies that the adoption was completed in accordance with the Hague Convention on Inter country Adoption. Children adopted through ASC by Canadian families are eligible for dual citizenship in the U.S. and Canada. We hope that this information has answered your initial questions about adopting through Adoption by Shepherd Care. In our private consultations, prospective adoptive parents are acquainted further with the process of adoption through our agency during a one on one phone call with either our Director or Canadian Program Coordinator. Scheduling a consultation is the first step toward working with our agency, and you may do so by completing the attached Preliminary Application and returning it to our Hollywood office along with the consultation fee of $250, which is payable in the form of a money order, cashier s check, or bank draft in US funds. We look forward to speaking with you soon! Revised 4.26.11 Thank you for your interest in Adoption by Shepherd Care, and best to you as you continue your adoption journey.
PROGRAM STATEMENT Adoption by Shepherd Care (ASC) was founded in 1980 based on Christian principles and the desire to serve women involved in crisis pregnancies and families wanting to build their family through adoption. Adoption by Shepherd Care meets the needs of birth parents struggling with unplanned pregnancy and prospective parents building their families through adoption. ASC is a Hague-approved, Florida-licensed child-placing agency. ASC has offices in Hollywood, West Palm Beach, and Central Florida. Agency staff members are skilled and experienced professionals who have both the heart to serve birth parents and the professional knowledge to help them through the adoption process. ASC recognizes that your primary goal is to adopt a child. The agency is committed to providing the best quality adoption services. TYPES OF CHILDREN PLACED: *Healthy infants and babies less than one year old, including Caucasian, African American, Hispanic, & Biracial (African American/Caucasian) *Children with medical, developmental and special needs *Older children TYPES OF PLACEMENTS: *Agency matched adoptions *Designated adoptions, providing all services *Trans racial adoptions *Interstate adoptions *Special needs adoptions ELIGIBILITY: *Married couples whose average age does not exceed 50 years and neither spouse is older than 52. *Single applicants are eligible to apply for specific international programs. April 21, 2011 Page 1
SERVICES PROVIDED: Free information meetings Private consultations Domestic and Hague approved international adoption services Adoptive parenting classes Coordination of all legal requirements Interstate Compact for the Placement of Children (ICPC) Domestic post placement supervision International post adoption reports Birth parent interviews available Birth parent support services including adoption counseling, assistance with transportation, Medicaid applications, living arrangements, facilitation of post placement photo exchanges FEE SCHEDULE AND DESCRIPTION OF ADOPTION SERVICES Not every fee will apply to each individual situation. Effective date of this fee schedule is 4/21/11 Fees are reviewed periodically and are subject to change. LIVING EXPENSES FOR THE BIRTHMOTHER: According to Florida Statute 63.097 (2)(a)(b) allows for reasonable living expenses of the birthmother to be assessed and paid through the adoption entity on behalf of the prospective adoptive parents. Reasonable living expenses of the birth mother which the birth mother is unable to pay due to unemployment, underemployment, or disability are rent, utilities, basic telephone service, food, toiletries, necessary clothing, and transportation, insurance, medical and expenses found by the court to be necessary for the health and well-being of the birth mother and the unborn child. Such expenses may be paid during the pregnancy and for a period of up to 6 weeks postpartum. COUNSELING SERVICES (ADOPTION) 1. CLIENT CONTACT AND CASE MANAGEMENT: $125 per hour The cost of serving the birth parents and/or adoptive family will be charged at the hourly rate of $125, and will begin with the first contact the birth parents have with the agency. 2. TRAVEL TIME: $50 per hour This fee is for the time spent by the caseworker traveling to meet with the birth mother or birth father or any other travel time related to the case. April 21, 2011 Page 2
3. Program Caps Capped: Client contact/case management time will be capped at 15 hours. You will not be charged for travel time. Partially Capped: Client contact/case management time will be capped at 30 hours. You will not be charged for travel time 4. MILEAGE/TOLLS: The current mileage rate allowed by the IRS is $0.51 cents per mile. Mileage applied to your specific case will be for all services to the birth mother, prospective adoptive parent s home study, home study updates, and post placement visits. Tolls incurred for all programs will be applied to each case. PRE AND POST PLACEMENT SERVICES 1. CANADIAN CONSULTATION FEE: $250 This fee applies to those Prospective Adoptive Parents that reside in Canada desiring to adopt from the US. This consult is approximately 1½ hours in length. We will discuss Florida adoption laws, US Department of State, and Canadian Government requirements/process according to the Hague Convention. We will explain the entire adoption process during this time, how we work with a birth mother, acceptance factors, fees, next steps, and all of your questions. The consultation fee is due with the submission of your Preliminary Adoption Application. 2. DOMESTIC CONSULTATION: $175 This is an opportunity for prospective adoptive parents to obtain comprehensive information about adoption options available to them through Adoption by Shepherd Care domestically. The consultation fee is due with the submission of your Preliminary Adoption Application. 3. POST PLACEMENT SESSIONS: $250 per visit + mileage & travel Requirements for post placement supervisory reports vary from state to state. All ASC adoptions require three visits during the first 90 days following placement. Travel time for Post Placement visits, in excess of one hour, will be charged at the rate of $50/hour. 4. INTERNATIONAL POST ADOPTION SUPERVISION: $350 per visit + mileage & travel Requirements for post adoption supervisory reports vary from country to country. It is the adoptive family s responsibility to contact ASC upon their return from the placement of their child. Each adoptive family s international program will need to send ASC their international post placement requirements. Travel time in excess of one hour will be charged at the rate of $50/hour. April 21, 2011 Page 3
5. INCLUSION FEE (NON-ASC HOME STUDY): $850 Prior to inclusion in ASC s Caucasian/Hispanic adoption Program, the family must submit an Adoption Services Application along with an original home study and any subsequent updates. Families pursuing a designated adoption are not required to pay this fee. 6. INCLUSION FEE (WITH ASC HOME STUDY, CAPPED AND PARTIALLY CAPPED PROGRAMS): $250 This fee applies to families who have used ASC to complete their home study and prospective adoptive parents in ASC s Capped and Partially Capped Programs. 7. CANADIAN PROGRAM FEE: $1,200.00 This fee applies to families who reside in Canada and adopt through ASC. It covers your registration, dossier preparation as well as casework time and documentation necessary to facilitate an international adoption. This fee covers ASC s evaluation of the home study and supporting documents in order to assure compliance with all requirements of the Hague Convention through the Department of State and Canada s Central Authority. It also includes ongoing required monitoring through the Adoption Tracking System (ATS). (The Canadian Program Fee is due at time of application.) 8. INTERSTATE COMPACT FEE: $1000 This fee only applies to US families who live outside Florida. It covers the agency s expenses in obtaining approval from ICPC for the child to leave the state of Florida and enter your state of residence. This fee is due at the time of placement. 9. SSI/SUBSIDY APPLICATION FEE: $1,000 SSI/Subsidy does not apply to most adoption situations. In those relatively rare cases when medical records reflect that an infant or child may be permanently disabled and may meet state and Federal guidelines for such assistance, an SSI/Subsidy application fee of $1,000 will be due at the time of placement. This fee will cover the first ten hours of the SSI/Subsidy process. After the first ten hours, the family will be billed at the rate of $75 per hour. Adoption by Shepherd Care reserves the right to refuse to apply for SSI/Subsidy in certain cases. ASC cannot guarantee that SSI/Subsidy will be approved. 10. INTERIM CARE EXPENSES: $50 per day If agency interim care is required, the fee is $50 a day plus expenses, including the day of entry and the day of discharge. April 21, 2011 Page 4
HOME STUDY SERVICES 1. DOMESTIC ADOPTIVE HOME STUDY: $1,500+mileage & travel Following the consultation, a $1000 deposit is due to initiate the home study process. The remaining $500 plus mileage and travel time is due at the completion of the home study. Travel time for Domestic Adoptive Home Study, in excess of one hour, will be charged at the rate of $50 per hour. We reserve the right to determine whether or not we will be able to proceed with your home study based on many factors. You will be required to submit information regarding prior arrests, regardless of whether the records have been sealed or expunged. The home study is valid for one year and must remain current through placement. As part of the home study process, all families will be required to complete an MMPI- II and psychological evaluation administered by a licensed psychologist. A fee will be charged by the psychologist for these services. 2. INTERNATIONAL ADOPTIVE HOME STUDY $2,250+mileage & travel With the submission of your Adoption Services Application, a $1500 deposit is due to initiate the home study process. The remaining $750 plus mileage and travel time is due at the completion of the home study. Travel time in excess of one hour will be charged at the rate of $50 per hour. ASC reserves the right to charge additional fees dependent on the specific requirements set forth by the adoptive family s international program of choice. We reserve the right to determine whether or not we will be able to proceed with your home study based on many factors. You will be required to submit information regarding prior arrests, regardless of whether the records have been sealed or expunged. If you have had any legal charges brought against you, including but not limited to misdemeanor or felony charges, a $250 fee will be assessed for the additional time required in assisting you with your USCIS approval. 3. DOMESTIC ADOPTIVE HOME STUDY UPDATE: $750+mileage & travel For families whose homestudy was done by ASC, we will complete one update. After two years a full home study will be required. With the submission of your Adoption Services Application, the payment of $750 is due. The balance of mileage and travel time will be paid at the completion of the home study update. Travel time in excess of one hour will be charged at the rate of $50/hour. April 21, 2011 Page 5
4. INTERNATIONAL ADOPTIVE HOME STUDY UPDATE: $1,250 + mileage & travel For families requiring an I-800A, a full home study will be required. An adoptive home study update is required when the original home study or the most recent home study update has expired. With the submission of your updated Adoption Services Application, the payment of $1,250 is due. The balance of mileage and travel time will be paid at the completion of the home study update. Travel time in excess of one hour will be charged at the rate of $50/hour. 5. RUSH HOME STUDY OR RUSH UPDATE: $250 + Cost of Home Study or Update + all Additional Fees (e.g., mileage, travel time, Fed Ex, postage, etc.) The Rush Homestudy fee must be paid in full before first visit. LEGAL SERVICES: Amount dependent on circumstances of case and program 1. Notice of Intended Adoption $1200 2. Filing fee and Document preparation $575 3. Petition for Declaratory Statement $1200 4. Diligent Search for birth father $300 (if required) 5. Publishing for birth father $400 $500 (if required) 6. Hague Adoption Hearings Fee $1500 7. Petition for Termination of Parental Rights $1350* 8. Petition for Adoption (Finalization) $1350* 9. Legal Miscellaneous TBD *Reduced fees for capped and partially capped programs AGENCY ADMINISTRATIVE FEE: $13,500 The agency s administrative fee is $13,500. This fee is paid at the time of placement of the child into your home. This fee aids in covering the costs of maintaining all accreditations, licenses, approvals, insurances, and the ongoing daily operations of the agency. It also includes the agency s expenses for advertising including yellow pages, web site. In addition, it includes Putative Father Registry Search, Child s birth certificate, application for baby & birthmother Medicaid, fees for baby & birthmother medical records, witnesses & notaries fees, court reporters, & ASC s portion of legal expenses incurred (doc prep). DESIGNATED ADOPTION FEE: $4,250 For those families that have made their own connection with a birthmother and require the services of Adoption by Shepherd Care, a Designated Adoption Fee will be applied. Upon acceptance of a Contract and Estimate ½ of the Designated Adoption April 21, 2011 Page 6
Fee is due. The Agency Administrative Fee will not be applied to your case. However, all other fees including Living Expenses to the Birthmother, Adoption Counseling Services, Pre & Post Placement Services, Home Study Services, Legal services, and any other fees will apply to your case in accordance with Florida statutes. The balance of the Designated Adoption Fee will be due at placement. ESCROW: varies according to the particular case An initial deposit is required ($5,000-$7,000) once the prospective adoptive parents agree to go on the case. You will be considered matched once you pay this escrow amount and sign a Contract for Domestic and Designated Adoption Services and an Estimate. These funds will be applied towards Living Expenses for the Birth Mother, Adoption Counseling Services, and Legal Services as they are incurred on behalf of the birth parent or adoptive family including but not limited to: appointment time, hospital time, court time, telephone time, conference time, document preparation time, research and writing time. These funds will also be used for actual birth parent living, medical, and legal expenses as they are incurred. Additionally, the prospective adoptive family will be invoiced to maintain the escrow amount required. If a birth parent chooses not to continue with their adoption plan, any unused escrow will be refunded to the prospective adoptive couple. If the adoptive couple chooses to withdraw from the contract, unused escrow funds will be refunded. DISBURSEMENT OF REFUNDS: At the conclusion of any and all adoption services, an expense analysis is completed. If a client is owed a refund, the agency will reimburse all funds within thirty days of the completion of the expense analysis. April 21, 2011 Page 7
Adoption by Shepherd Care PROFESSIONAL ADOPTION SERVICES www.adoptabsc.org Preliminary Adoption Application Corporate Office: 5935 Taft St. Hollywood, FL. 33021 Phone: 954-981-2060 Fax: 954-981-2117 adopt@adoptabsc.org Central Florida: 2911 Lakeview Dr. Fern Park, FL 32730 Phone: 407-265-9599 Fax: 407-265-9549 orlando@adoptabsc.org Please send this completed application, two signed Acknowledgements of Receipt of Disclosure and the consultation fee to the Adoption by Shepherd Care Corporate office address. As soon as we receive it, we will call you to set up your consultation appointment. Today s Date: Husband s Name: Wife s Name: Address: first first last last Date of Marriage: Date of Birth: Date of Birth: City/State/Zip: Telephone (home) His Work # Her cell # His cell # Her work # Email Children: Age Sex Bio/Adopted Palm Beach: 3405 Forest Hill Blvd. #104 West Palm Beach, FL 33406 Phone: 561-588-3649 adopt@adoptabsc.org Florida West Coast: St. Petersburg, FL Phone: 941-627-5929 Adoption Interest (Check as many as possible) Domestic Infant Caucasian International Older Child African-American Designated Special Needs Hispanic Asian Biracial: Cauc/Black Other Mixed Races If so, what races? adopt@adoptabsc.org Comments: Hague Accredited COA Accredited BBB Member FAC Member NCFA Member JCICS Member 501(C)(3) non-profit agency Infertility: Nature of Infertility Treatment: Probability of Conception How did you hear about Adoption by Shepherd Care? Other important Information 1.15.2010
Adoption by Shepherd Care PROFESSIONAL ADOPTION SERVICES www.adoptabsc.org Corporate Office: 5935 Taft St. Hollywood, FL. 33021 Phone: 954-981-2060 Fax: 954-981-2117 adopt@adoptabsc.org PAYMENT INFORMATION FOR CANADIAN FAMILIES Canadian families often have questions regarding acceptable forms of Central Florida: 2911 Lakeview Dr. Fern Park, FL 32730 Phone: 407-265-9599 Fax: 407-265-9549 orlando@adoptabsc.org payment to Adoption by Shepherd Care. Please note that we are only able to receive payments in the form of a money order, cashier s check, or bank draft in US funds. The money order, cashier s check, or bank draft should be made payable Palm Beach: 3405 Forest Hill Blvd. #104 West Palm Beach, FL 33406 Phone: 561-588-3649 adopt@adoptabsc.org to Adoption by Shepherd Care in US Dollars. Please write your first and last name on the money order, cashier s check, or bank draft to ensure that the payment is credited to your account. We are unable to accept personal checks from Canadian families due to Florida West Coast: St. Petersburg, FL Phone: 941-627-5929 adopt@adoptabsc.org bank policies, and we are not able to process payments by credit or debit card. If you have any questions regarding our fee policies, feel free to contact us at 954-981-2060. Hague Accredited COA Accredited BBB Member FAC Member NCFA Member Thanks! Adoption by Shepherd Care JCICS Member 501(C)(3) non-profit agency Revised 12.14.10
ADOPTION DISCLOSURE THE STATE OF FLORIDA REQUIRES THAT THIS FORM BE PROVIDED TO ALL PERSONS CONSIDERING ADOPTING A MINOR OR SEEKING TO PLACE A MINOR FOR ADOPTION, TO ADVISE THEM OF THE FOLLOWING FACTS REGARDING ADOPTION UNDER FLORIDA LAW: 1. The name, address, and telephone number of the adoption entity providing this disclosure is: Name: Adoption by Shepherd Care Address: 5935 Taft Street Hollywood, Florida 33021 Telephone Number: (954) 981-2060 2. The adoption entity does not provide legal representation or advice to birth parents, and birth parents have the right to consult with an attorney of their own choosing to advise them. 3. With the exception of an adoption by a stepparent or relative, a child cannot be placed into a prospective adoptive home unless the prospective adoptive parents have received a favorable preliminary home study, including criminal and child abuse clearances. 4. A valid consent for adoption may not be signed by the birth mother until 48 hours after the birth of the child, or the day the birth mother is notified in writing, that she is fit for discharge from the licensed hospital or birth center. A putative father may sign a valid consent for adoption at any time after the birth of the child. 5. A consent for adoption signed before the child attains the age of 6 months is binding and irrevocable from the moment it is signed unless it can be proven in court that the consent was obtained by fraud or duress. A consent for adoption signed after the child attains the age of 6 months is valid from the moment it is signed; however, it may be revoked until the child is placed in an adoptive home or up to 3 days after it was signed, whichever period is longer. 6. A consent for adoption is not valid if the signature of the person who signed the consent was obtained by fraud or duress. 7. An unmarried biological father must act immediately in order to protect his rights with regard to the child. He must register his paternity with the Florida Putative Father Registry maintained by the Office of Vital Statistics of the Department of Health within the timeframes set forth in 63.062 and he must provide the child with financial and physical support by assisting the mother during her pregnancy and providing for the child after birth. Section 63.062 prescribes that any father seeking to establish his right to consent to the adoption of his child must register his paternity with the Putative Father Registry no later than the date a petition to terminate parental rights is filed with the court. If a putative father is served with a Notice of Intended Adoption Plan, he must register his paternity, file a parenting plan with the court and provide financial support to the mother and/or the child within 30 days of service of the Notice of Intended Adoption Plan. Any putative father may obtain a registration form through local offices of the Department of Health, Office of Vital Statistics; Department of Children and Families, the Internet websites for these agencies, and the offices of the clerks of the circuit courts in the State of Florida. The claim of paternity form must be submitted to the Office of Vital Statistics, Attention: Adoption Unit, P.O. Box 210, Jacksonville, FL 32231. 8. There are alternatives to adoption, including foster care, relative care, and parenting the child. There may be services and sources of financial assistance in the community available to birth parents if they choose to parent the child. initials
9. A birth parent has the right to have a witness of his or her choice, who is unconnected with the adoption entity of the adoptive parents, to be present and witness the signing of the consent or Affidavit of Nonpaternity. 10. A birth parent 14 years of age or younger must have a parent, legal guardian, or court appointed guardian ad litem to assist and advise the birth parent as to the adoption plan. 11. A birth parent has a right to receive supportive counseling from a counselor, social worker, physician, clergy, or attorney, and such counseling would be beneficial to the birth parent. 12. The payment of living or medical expenses by the prospective adoptive parents prior to the birth of the child does not, in any way, obligate the birth parent to sign the consent for adoption. ACKNOWLEDGEMENT OF RECEIPT OF DISCLOSURE I, and, the undersigned (print name) (print name) herein confirm by our signatures below that we have received the Adoption Disclosure required by Section 63.085 of the Florida Statutes and provided to us by Adoption by Shepherd Care. Received this day of, 20. Adoptive Mother Signature Adoptive Father Signature I witnessed the signatures before me on this day of, 20. Witness Signature Witness Printed Name
ACKNOWLEDGEMENT OF RECEIPT OF DISCLOSURE I, and, the undersigned (print name) (print name) herein confirm by our signatures below that we have received the Adoption Disclosure required by Section 63.085 of the Florida Statutes and provided to us by Adoption by Shepherd Care. Received this day of, 20. Adoptive Mother Signature Adoptive Father Signature I witnessed the signatures before me on this day of, 20. Witness Signature Witness Printed Name