Applicants names:(first & last names of each adopting parent)

1.

2.

 Please include information for This Year and Last Year

Annual Income: Self/Wife £½¡ç

Self/Husband £½¡ç

Other Annual income: Self/Wife £½¡ç

Self/Husband £½¡ç

Life Insurance: Self/Wife £½¡ç

Self/Husband £½¡ç

ASSETS: (VALUE)

Vehicles ¡ç

Personal Property ¡ç

Real Estate: Residence ¡ç

Other ¡ç

Stocks/Bonds ¡ç

Savings Account(s) ¡ç

Checking Account(s) ¡ç

Other Investments ¡ç

¡ç

¡ç

¡ç

TOTAL ASSETS: (Not including income & insurance) ¡ç

LIABILITIES: MONTHLY PAYMENT: TOTAL OWED:

Credit Cards ¡ç $

Bank Loans ¡ç ¡ç

Home Mortgage ¡ç ¡ç

TOTAL LIABILITIES: ¡ç

NET WORTH: ¡ç

I/We attest that the above information is an accurate summary of my/our assets, liabilities and other information.

Signature 1.

Signature 2.

NOTES TO REMEMBER:

• Please type. Do not handwrite.
• This is merely a guide to help you. Please adjust it for your specific assets and liabilities.

TO EXAMINING PHYSICIAN:

In evaluating the applicant, this agency and the China Center of Adoption Affairs must be guided by your medical findings as reported on this form. Thank you for your assistance, Please print or type all information. Note ¡°N/A¡± of ¡°none¡± if applicable. Please do not leave blank.

Applicant's Name£º

DOB:

Address£º

Medical History

Please answer in this order: No/Yes/Time/Result

Have you ever had Tuberculosis?

Tumor£¿

Heart disease£¿

Liver disease£¿

Sexual disease£¿

Neuropathy£¿

Mental disease£¿

Other communicable disease?

Alcoholism or history of substance abuse?

Any genetic disease£¿

Any surgical operations£¿

PHYSICAL EXAMINATTON£º

Date of exam:

Height:

Weight:

Blood pressure:

Vision:

Hearing:

Heart:

Liver:

Lungs:

Lymphatic system:

Thyroid:

Nervous system:

Uroscope:

Blood test results:

HIV: pos/neg

What is your assessment on the patient's fertility/infertility?

Is the patient taking any medication?

PHYSICIAN'S STATEMENT£º

Signed: MD

License No.

Date:

Physician's name:(Print clearly)

Address: