Ministry of Ukraine for Family, Youth and Sports
The State Department for Adoption and Protection of the Rights of the Child
Adress: 14 Desyatynna Street, Kyiv 01025, Ukraine



--FATHER--
Citizen of the United States of America
Passport No. ---------------------
Issued by Passport Agency
Washington, D.C.
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U.S.A.
HOME ADRESS_______________________________
_____________________________________________
Home Phone: ----------------------


--MOTHER--
Citizen of the United States of America
Passport No. -------------------
Issued by Passport Agency
Washington, D.C.
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------------------------------------------
U.S.A.
HOME ADRESS_______________________________
_____________________________________________
Home Phone: ----------------------
FAX: ------------------------------


                                       PETITION TO ADOPT

We, ------------------------------ and -------------------------------, petition to register us candidates for adoption of an  orphaned or  abandoned child.  We ask  permission to  visit 
orphanages and re-run  children's homes  to select,  make contact with,  and  get  acquainted with (a) child/children that we desire and intend to adopt. We  desire to  adopt  one or  two  children  of  either sex, 
between one and five years, with a minor, surgically or medically correctable condition of any race.


We are submitting the following documents: 
Adoption Home Study
Form I-171H, Notice of Approval of Advance Processing, entrance and permanent residence permit for the adopted child. 
Statements of Employment for each prospective parent. 
Statements of Health from a physician for each prospective parent. 
Copies of Marriage Certificate. 
Copies of Passports of prospective parents. 
Letter of Clearance from the Police.
Letter of Obligation
Home ownership/Rental Document
Notarized Statement for Interpol Clearance


_________       ________
Signature        (date) 


_________       _______               
Signature       (date)

State of ---------, County of ----------
Sworn to and subscribed before me on this ______ day of ______________, 200__.


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                                    / Certified Notarially /

My commission expires: _____________


Date: _____________

Signature: __________________

________________________________________
------------------, Notary Public 
Address:------------------------------------ 
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STAMP