Case Name____________________________ Social Worker__________________________________
|
DOCUMENT |
HUSBAND |
WIFE |
COMMENTS |
|
Autobiography (optional) |
|||
| Birth Certificate | |||
|
Adoption
Decree/ |
|||
|
Marriage Certificate |
If applicable |
||
|
Divorce Certificate |
If applicable |
||
|
Death Certificate |
If applicable |
||
|
Employment Letter |
|||
|
Financial Description |
|||
|
Fire Escape Plan |
|||
|
W-2 Copy |
|||
|
Medical |
Necessary for all household members |
||
|
Police Clearance |
Needed for household members >18 |
||
|
CPS Clearance |
Needed for household members >18 |
||
|
3 Reference Letters |
|||
|
Sworn Disclosure |
|||
|
Corporal Punishment |
|
DATE OF VISIT |
WHERE VISIT WAS CONDUCTED |
||
All documents on this list, excluding Fire Escape Plan, W-2 Copy, Autobiographies must be notarized using the following format.
Correct Format for Notarization
Sworn and subscribed before me this _______day of ________________, 200____.
_________________________
Notary Public
City / County of ____________________
__________________________________
State
My Commission expires on:_______________________________________________
( Also remind notary to place her/his raised seal on the document)