A Child Waits FoundationDomestic Adoption Grant Program

1136 Barker Road, #12Pittsfield, MA 01201

Phone: 866-999-245 Fax: 518-794-6243Email: cnelson@achildwaits.org Web: wr.r,w.achildwaits.org

Grant Application Instructions. A Child Waits Foundation accepts applications after a homestudy has been approved and prior

to your adoption being complete.. The grant request should include: the six application forms, supporting documents and $20

application fee. Please request that your social worker send us the required recommendationform.

. Provide a cover letter that describes the process or journey you have taken to get to this point andyour motivation to adopt. Include information about your fundraising efforts, donations, helpfrom extended family, and other grants you have applied for or received. If you have alreadybeen matched with a child, please include information about the child or children you areadopting.

, Do not fax or email applications, please mail to:

Mailing Address:A Child Waits FoundationAttn: Grant Department

P0 Box 145

West Lebanon, NY 12195lf sending FedEx or UPS and a physical address is required, please send to:

A Child Waits Foundation1221 State Route 20

New Lebanon, NY 12125

After the Application has been Mailedo About 3 weeks after you submit your application call to check that your file is complete.. Once the application is complete, you may be contacted for additional information prior to

submission to our Board.. If there ate any changes regarding your adoption, please notify the Foundation.. All grant applicants receive notification regarding the outcome of their grant request. Since the

circumstances of each adoption vary, the payment of grant funds may be different for eachapplicant. We work with every approved family to determine the best time to fund the grant.

. Funds may be used for all direct adoption costs including tuavef if necessary.

. Our process is ongoing and applications are accepted at any time during the year. There are noapplication deadlines to be met.

. Under special circumstances A Child Waits Foundation can expedite the grant review process ifthe adoption will be completed faster than anticipated.

NotificationOnce a decision is made regarding your application, you will be notified by mail or by phone.AII decisions are final and we do not allow re-application of denied applications.

After you a.re HomeA Child Waits Foundation requests a brief summary of your adoption and pictures after yourchild is home. If the famiiy gives ra,ritten consent, A Chjld Waits Foundation may use yourpictures and adoption summarv on our web site.

A Child Waits Foundation Grant Application1136 Barker Road, #12,Piftsfield, MA 01201.

Phone: 866-999-2445 Fax: 578-794-6243

Email: cnelson@achildwaits.orgWeb: www.achildwaits.org

Domestic Grant Program Documents Checklist

Family Name: Date:

Please use this checklist to confirm you have included all necessary documents. Everything on thischecklist must be received before your apptication can be processed. Thank you!

Application Mailing Address:A Child Waits Foundation

PO Box 145West Lebanoru NY 12195

If sending FedEx or UPS and a physical address is required please send to:A Child Waits Foundation

l22'LState Route 20New Lebanon, NY 12125

Please be sure to confirm that the recommendation form has been received by A Child Waits Foundation.Applications will not be considered complete or processed i{ this form is not received. Any false ormisleading answers on the application or subsequent documents will be grounds to decline approval orrevoke a grant that has already been approved.

! A Child Waits Forms

Grant Application - Family / Adoption Inf ormation

Financial Statement

Monthly Budget Form

Adoption Expense Form

Grants, Fundraising and Donations Form

Consent Form

Supportin g Documents/OtherHome study

Cover letter - See instructions to be sure your cover letter includes the requested information.

Most recent 1040 with attachments - include schedule C if business owrrer

Most recent copy of pay stub for all applicants

Picture and medical of child being adopted

Picture of current family

$20 application fee

home studv social worker to complete and send Recommendation Form.

A Child Waits Foundation - Domestic Grant ApplicationFamily and Adoption Information

Adoptive Parent L Adoptive Parent 2

Age:

-

Ase:Name:

Email:

Cell: Textins: Yes No

Best # to be reached: Cell Home

Name:

Email:

Cell: Textins: Yes No

Best # to be reached: Cell Home

Home Address, City, State, Zip:

Home Phone: Marital Status: Sinsle Married Other

Social Media Sites/Adoption BIog:

# of Children: Adopted

Current Family Profile

: Biolosical: Foster: Anv children with special needs? Yes / No

If yes, please explain:

# of Children living at home: Name and ages:

is the child or children being adopted currently living in your home? Yes/No If yes, how long?

Name and ages of any others residing in household:

Adoption Process Information

Is this an interstate adoption? Yes/No - If adoption related travel is required please provide information below:

City/State:Number of Required Trips:

Expected travel date trip 1:

Expected travel date trip 2:

Family members traveling trip 1:

Family members traveling trip 2:

Projected date for completion of adoption:

Child to be Adopted

Name Age Sex Special Need

Attorney/ Adoption Agency Name:

Address:

Attorney/Agency Inf ormation

Contact Person:

Home Study Agency Name:

Address:

Phone:

Contact Person:

How did you hear about A Child Waits Foundation?

Phone:

A Child Waits Foundation Domestic Grant ApplicationFinancial Statement

Adoptive Parent 1 Adoptive Parent 2

Occupation:

Employer:

Projected Income for Current Year: Projected Income for Current Year:

Other Yearlv lncome: Source:

Occupation:

Employer:

(Social security, disability, retirement, military,

foster care/adoption stipends, etc.)

Other Yearlv lncome: Source:

(Social security, disability, retirement military,

foster care/ adoption stipends, etc.)

]oint Assets and

Assets-WhatIOwn:

Home (estimated market value)

2"d Home (current market value)

Total Savings & Checking

Stocks and Bonds

401K/ Retirement Accounts

Other Assets (describe):

Total of All I Own

Can you borrow from your retirement for this adoption? Yes

Liability Information

Mortgage on 1"t Flome

Mortgage on 2"d Home

Home Equity Loan/Credit

Education Loans

Credit Cards

Other Liabilities (describe):

Total of Liabilities

Total of All I Own

Total of Liabilities

Total Net Worth

Liabilities - What I Owe:

Reason:

Can you borrow against your home for this adoption?

Reason:

Yes _ No

Will you receive any employer reimbursements before or after the adoption is complete?

Yes _ No Before After

-

Amount: $

Will you receive any sta

Yes_ No_What amount of money

te reimbursements before or after the adoption is complete?

Before After

-

Amounl $.

do you have saved to put toward the adoption? $

Are there any past credit issues, such as bankruptcy or late payments? Yes

If yes, please explain:

No

A Child Waits Foundation Domestic Grant ApplicationMonthly Budget

Name: Date:

Net Monthly Income - fncome after Taxes:

Adoptive Parent 1

Adoptive Parent 2

Other Household Members

Child Support/ Foster Care/ Adoption Stipends

Bonus

Other (social security, disability, retirement,militarv, etc.)

1. Total Monthly Income $

Monthly Household Expenses:

Mortgage/RentHome Equity LoanUtilities/ InternetInsurance (house, life, medical, etc.)

Groceries/ Personal Care Items

Medical/ Prescription Expenses

ClothingParent/ Child Educational Expenses

Entertainment/ Extracurricular ActivitiesCar Expenses

OtherOther

2. Total Expenses $

4. Monthly Income (Enter amount from line 1)

5. Grand Total of Monthly Expenses (Enter total of line 2 & 3) $

Loans and Credit Cards - Exclude Expenses Already Listed Above:

Name of Bank/Lender Current Balance Monthly Payment

3. Total Loans and Credit Cards $

6. Money Left After Paying Bills (Subtract line 5 from tine 4)

Familv Name:

A Child Waits Foundation Domestic Grant ApplicationAdoption Expenses

Date:

Total Cost Amount Paid

Home Studv/Updates and Related Fees

Post Placement Fees Paid Before Placement

Post Placement Fees Due After Placement

Trip:1 Food and Lod

T r ip 2: Fkg,ht / T r av el / T t

Trip:2 Food and

A Child Waits Foundation Domestic Grant ApplicationGrants, Fundraising and Donations

What grants have you been awarded? Please list amounts and providers below. Please use back ofform for additional information if necessary.

Grants AwardedMatching

Amount Funds Received Funds Used Grant

What other grants have you applied for that are still pending, resubmitted or denied? Please listwhere you applied and the status of application:

If you have fundraised or plan to fundraise, please list all fundraisers below. Please indicate if thefundraiser has been completed and how much money has been raised.

FundraisinCompleted/

PlannedAmountRaised

Amount

If you have received any donations from friends, family or church, please list below:

Name Amount Name Amount

List any social media fundraising or crowdfunding sites:

1 Yes No Yes No Yes No2 Yes No Yes No Yes No3 Yes No Yes No Yes No4 Yes No Yes No Yes No5 Yes No Yes No Yes No

7

2

3

4

5

6.7

8

9

10

Have you used loans or used credit cards to pay adoption costs?

Yes:- No:- Amount: $

Factoring in all available funds, either received or projected what is your estimated remaining need:

$

A Child Waits Foundation Domestic Grant ApplicationConsent Form

(adoptive parent) and I (adoptive parent)

please print name please print name

1. Give our adoption agency, attorney or other adoption professionals permission to speak with andshare information pertaining to our adoption with A Child Waits Foundation.

2. If necessary, give A Child Waits Foundation permission to obtain a recent credit report for the

purpose of grant determination. This is seldom done, however, if the Foundation determines it isnecessary, the applicant will be notified before a credit report is obtained.

3. Understand that any false or misleading answers on the application or subsequent documentswill be grounds to decline approval or revoke a grant that has already been approved.

4. For the benefit of A Child Waits Foundation's Board of Directors, if given a grant we agree toprovide our adoption summary and photographs once our adoption is complete.

Yes No

5. Once the adoption process is complete, we give A Child Waits Foundation the right to use ouradoption summary and/or photos and images of our family on their website, and/or printedmaterial, with the purpose of helping other families who are adopting. Unless additional writtenpermission is giverq A Child Waits will not use names, city, state or other identifyinginformation.

Yes- No

Signature Date

Adoptive Parent

Signature Date

Adoptive Parent

A Child Waits Foundation Domestic Grant ApplicationL136 Barker Rd, Unit 12

Pittsfield, MA 01201Phone: 866-999 -2M5 Fax: 518-7 94-6243

Email: deanna@)achildwaits.org Web: wwwjrchilclwaits.org

Social Worker Recommendation Form

A Child Waits Foundation provides grants and low-interest loans to families to help with some of the financialbarriers to adoption. Our programs are designed to help families who are able to personally pay a portion of thecost of the adoption but need additional assistance. Please mail, email or fax this form to the Foundation usingthe information provided above.

Adoptive Paren(s Name(s) and Phone Numbers:Home Study Agency: Date:Name of Person Completing Form: Phone:

What concerns did the family express about affording the adoption when they first started the adoptionprocess?

Are there any issues or concerns regarding the successful completion of this adoption?

Will a grant impact the family and their ability to complete their adoption? r Yes r NoPlease explain.

What is an estimated total cost to the family for the adoption, including home study, attorney, kavel and anyother direct adoption costs?

On a scale of 1 - 10, 1 representing no need and 10 representing great need, how would you rate this family incomparison to other families for whom

Information about child being adopted:

you have approved a home study?

If the family is approved for a grant, A Child Waits Foundation will need to confirm details of the timing of theadoption process in order to determine the best time to release the grant funds. If you have the contactin{ormation for the best person to provide this information, please complete the following:Name of Organization:Contact Person's Name & Title:Phone: Email:

Additional Comments:

Signature: Date:

The family has given us written permission to request this information. Thank you for taking the time tocomplete this form. If you would like us to send your agency brochures about our loan and grant program,please provide your name and mailing address: