Private Adoption Entity Checklist from Mississippi to Another State – A private

Private Adoption Entity Checklist from Mississippi to Another State – A private adoption packet should contain the following documents [five (5) copies of the 100A and three (3) sets of every other document]: 1. 100A completed on each child (Type 100A) to include: a. Child’s name consistent with name on birth records or explanation; b. Proof why different Date of birth consistent with DOB on birth records; c. Correct entity for planning/financial responsibility; d. Prospective adoptive parent name/address/phone number; e. Lists where adoption finalized; f. Sending agency custody; and g. Name and address of supervising agency/individual. 2. Cover letter that includes: a. Shows name and phone number of agency or Partner Provider handling the adoption Indicates adoption will be finalized in Mississippi; b. Addresses how birth/legal father(s) rights will be terminated (if applicable) Lists all contents of packet; and c. Signed by entity representative. 3. Notarized consent signed by birth mother a. Signed and notarized within seventy-two (72) hours after the birth of the child, or b. Within ten (10) days if Indian Child Welfare Act (ICWA) applies 4. Consent signed by birth father. If no consent, be sure the cover letter addresses how termination of rights will be completed AND at-risk agreement 5. Social, family and medical information on birth parents, including physical description of birth mother and father(s) 6. American Indian statement. (If yes, proof that tribe was notified and ICWA at-risk agreement signed by prospective adoptive parents or signed statement by Indian birth mother that she does want the tribe notified and at-risk agreement signed by prospective adoptive parents) 7. Narrative/forms on birth mother/birth father history (reasons for decision to place child for adoption). Counseling summary reflecting that birth parents were advised of alternatives to adoption and that they chose adoption from available alternatives. 8. Hospital birth and delivery form a. Document must be legible (if child one is (1) year or older, must have copy of exam completed within six (6) months of proposed placement request) b. Legible copy of hospital discharge signed by a hospital official, which identifies child’s medical condition at time of discharge c. Copies of any medical reports/assessments, etc., if applicable d. If a child has any special needs a more detailed assessment is required and approval by MDCPS is needed for a child to leave state. 9. Home study within one (1) year with Partner Provider information a. Must include name, address, and phone number of the agency and individual completing home study b. Copy of current professional license c. Criminal history checks must be within twelve (12) months. (Criminal background, Central Registry check and fingerprinting). d. Post placement supervisory agreement 10. Legal Risk Statement a. Signed by prospective adoptive parents or Termination of Parental Rights Order on birth parents. b. Initial disclosure to adoptive parents/ receipt of disclosure signed by prospective adoptive parents