To be submitted to the court after being countersigned by the adoptive applicants Photograph of the child to be countersigned by both parents.

Name and address of the institution:

I. General information :

1. Name of the child :
2. Reference no. as per general register of the institution
3. Present age and date of birth:
4. Sex:
5. Religion(if known):
6. Where was the child born (institution, hospital, home):
7. In whose care is the child at present? If in foster care, state reasons why it had to be removed from the institution and the date on which it was removed:

II. Legal data :
(For court committed or remand children only)

1. Is the child on remand or committed to your institution:
2. Name of the committing court:
3. Age of the child at the time of Commitment:
4. Date of order of Commitment:
5. Period of Commitment:
6. Final date of release:
7. Section of the Juvenile Justice Act, 1986:
8. Date of admission to your institution.

Please enclose a copy of the Court Commitment Warrant:
If available, please enclose a copy of the Probation Officer’s report which he/she submitted to the Juvenile Court at the time of commitment of the child as also the Commitment Order for the court.

III. Social data :
Do not give identifying information such as name and address of the natural parent

1. Date of admission of the child to your institution:
2. How did the child come to your institution:

1. admitted directly by parent or any other guardian?
2. placed on remand or court committed or referred by the police? (Name of the committing court or police station should be given).
3. transferred from any other institution, and if so which one?
4. any other source?

3. Circumstances under which the child came to the original institution:
4. Reasons for seeking protection in the institution:
5. Available information on biological parent’s physical and mental health (if any history of mental illness, ailments such as diabetes, epilepsy, heart condition, etc.):
6. Social information about the relatives (including health and medical condition of the immediate family of the child’s biological parents):
7. In case relatives are alive, have they agreed to give away the child in adoption/guardianship and if so, whether written consent has been obtained:
8. Whether the relatives have established any contact with the child after his/her admission to your institution:
9. If the child is purely destitute, give information which will prove this:
10. If the child was abandoned some time after birth, say about 10 days, give details of how the child was being cared for during the intervening period:

IV. Physical and emotional development:

1. Attitude towards other inmates:
2. Relationship with relatives, staff and other adults including strangers:
3. Intelligence (if and where possible, I.Q. report should be enclosed):
4. If the child is school-going, give a detailed report of his/her standard, attendance, general interest in studies, progress, limitations if any:
5. General personality and description of the child:
6. Play activity and any specific talent:
7. Milestones of the child (for children below 18 months): Please mark yes/no
   Does the child...?

1. smile
2. turn over on its stomach
3. lift its head
4. grasp objects in its hand
5. crawl on its own
6. sit with support --------- without support ---------
7. stand with support ------- without support -------
8. walk with support -------- without support -------

8. Language development:

1. babbles incoherently
2. speaks few words incoherently
3. speaks few words clearly
4. speaks fluently
5. language/s spoken by the child

9. Dietary habits:
   Intake of : Liquid foods ----------- Semi solids -------- solids --------
10. Physical examination report (appended)
    I, Shri/Smt. ----------- , of ---------- (name of agency), do hereby certify that the information given in this form about the child is correct.
    Place: ---------- Signature : ------------------
    Date : ---------- Name : ----------------------
    Designation:
    We have read and understood the contents of this Child Study Report and are willing to accept as our adoptive child ------------------------ (fill in child’s name).
    (Signature of the male applicant) (Signature of the female applicant)
    (Name of the male applicant) (Name of the female applicant)
    Place:
    Date:

B. MEDICAL REPORT OF THE CHILD

Physical examination report (to be filled in by the examining physician)
Name of the child:
Sex:
Age:
Colour: skin ------ eyes ------ hair -----
Height:
Weight:
Head:
Feet:
Circumference (any defect):
Vision(number and condition):
Nose:
Teeth:
Chest:
Posoture:
Heart:
Spine:
Nervous System:
Legs:
Reflexes:
Abdomen:
Hearing (any defects):
Any other:
Immunizations:
B.C.G.:
Measles:
Triple Antigen:
Poliomyelitis:
Tests (to be completed wherever possible)
VDRL:
Tuberculosis:
Chest X-rays:
Urine analysis:
Stool:
Blood:
HIV:
H.P.B.:
Medical evaluation (pertinent information regarding the child’s physical condition):
General condition of mental and physical development observations of physician:

Date:
Physician’s signature:
Place:
Registration number:

We have read and understood the contents of this Physical Examination report and are willing to accept ----------- (fill in name of the child) with his/her given condition.
(Signature of the male applicant) (Signature of the female applicant)
(Name of the male applicant) (Name of the female applicant)

C. BIRTH AFFIDAVIT OF THE CHILD

I, Mr. ---------------, residing at -----------, Bombay, do hereby state on solemn affirmation as follows:

1. I say that I am the father of female minor born on ----------.

2. I say that the date of birth of my daughter is -------------. There is no other document or record stating the said date of birth of the said minor and no such other document can be traced by any amount of diligence.

3. It is therefore the intention of this document that it be used as Birthdate Certificate for all purposes allowed by the Law including the child’s school admission purpose.
Solemnly affirmed at Bombay
on this 13th day of December, 1990.
Before me

Notary

D. DOCUMENT OF SURRENDER (SINGLE PARENT)*

I, -------- aged ------- do hereby state as follows:

1. I delivered a child on ------- at ------. The said child is born out of wedlock and has been in my guardianship and custody thereafter.
2. I request the authorities not to disclose my full identity or address or whereabouts and do not wish to give any information of the father, or other relatives of the said child, because of social reasons.
3. I am the sole guardian of the said child and there is no other lawful guardian or father for the said child.
4. I say that I was helped by the authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039 to understand all implications of adoption of my child and I was specifically told that in case the minor whom I am abandoning, if adopted, I shall have no further contact with the minor. I have made this decision of abandoning the minor after due thought and consideration.
5. I say that I, without receiving any monetary and material consideration voluntarily of my own free will and volition and without any inducement, influence, coercion or fraud and without being under the influence of any person, drink or drug, have today handed over my aforesaid child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039 with the authority to Family Service Centre, Bombay to place the said child in adoption / guardianship with any suitable people.
6. I say that I have abandoned the said child because I am unable to look after, maintain, educate and bring up the child and have no relative, friend willing to do so. I further say that I was explained and given to understand that I can claim my child within three months from today. I have further been explained that if I do not reclaim my child during this period of three months the agency will be free to rehabilitate the child at its own discretion either in India or abroad. I further state that should any untoward event occur with regard to the child when in the agency’s foster care, I shall not hold the agency responsible.
7. I hereby declare that I have relinquished all my rights and claims to the said child and all reciprocal rights, claims and/or obligations of the parent and child between me and the said child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may in their discretion place the said child into any good family irrespective of religion, in India /abroad, or transfer the child to any institution for the purpose of adoption/guardianship or any suitable rehabilitation.

• *The sample documents are derived from the records of the Family Service Centre,Bombay.

8. I request the authorities of Family Service Centre, Bombay, not to disclose my name and identity, known to them, to person or persons or authority at any time and under any circumstances.
Read over and explained by me-

Full name:
Designation:
Address:
Witnessed by:
Full name:
Designation:
Address:
Dated this day of 1992:
Natural mother’s name , signature/thumb impression:
Signature.thumb impression of natural mother’s relative:

DOCUMENT OF SURRENDER (MARRIED COUPLE)

1. We, Mr. --------, aged --- years and Mrs. ----------, aged --- years do hereby state as follows :
2. We have been married for five years. We have two children, a female child aged four years, and a male child aged one and a half years. We say that with much thought and consideration, we have decided to give up our third child, that is, a female child, born on --------, in adoption. We are the sole guardians of the child and there is no other lawful guardian for the said child.
3. I am working as a newspaper vendor at Dadar and have no permanent shelter. My wife is in long-term hospital care since she is suffering from an advanced stage of tuberculosis which is terminal. My wife and I are finding it very difficult to provide for and look after three children. We have been explained that some kind of support and foster care can be arranged by Family Service Centre, in case we do not wish to abandon this child. However, in the best interests of the child, we have decided, by our own free will, to give up the said baby girl in adoption.
4. We say that we are helped by the authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039, to understand all implications of adoption of our child and we were specifically told that in case the minor whom we are abandoning, if adopted,we shall have no further contact with the minor.
5. We request the authorities not to disclose our full identity or address or whereabout and do not wish to give any information of ourselves because of social reasons.
6. We are aware that the Family Service Centre will act in the best interests of the child. However, in unforseeable circumstances, we shall not hold the agency responsible.
7. We say that without receiving any monetary and material consideration voluntarily, of our own free will and volition and without inducement, influence, coercion, or fraud and without being under the influence of any person, drink or drug, have handed over our aforementioned child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039, with the authority to Family Service Centre, Bombay, to place the said child in adoption / guardianship with any suitable couple.
8. We say that we have abandoned the said child because we are unable to look after, maintain, educate and bring up the said child and have no relative or friend willing to do so. We further say that we were explained and given to understand that we can claim our child within four months from today. We have further been explained that if we do not reclaim our child during this period of four months, the agency will be free to rehabilitate the child at its own discretion either in India or abroad.
9. We hereby declare that we have relinquished all our rights and claims to the said child and all reciprocal rights, claims and / or obligations of the parent and child between us and the child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may at their discretion place the said child into any good family irrespective of religion, in India / abroad or transfer the child to any institution for the purpose of adoption / guardianship or any suitable rehabilitation.
10. We request the authorities of Family Service Centre, Bombay, not to disclose our name and identity, known to them, to person or persons or authority at any time and under any circumstances.

Read over and explained by me-

Full name:
Designation:
Address:
Witnessed by:
Full Name:
Designation:
Address :
Witnessed by:
Full Name:
Relative of natural parents:
Address:
Natural mother’s name, signature/thumb impression:
Natural father’s name, signature/thumb impression:
Dated, this day of July 1991:

RELEASE DOCUMENT FOR CHILD ON REMAND

IN THE COURT OF THE METROPOLITAN MAGISTRATE: JUVENILE COURT:
UMERKHADI:BOMBAY; CASE NO. 333J/88

B/J was produced before this Court by Matunga Police station on 4-9-1988 and he was transferred to the Observation Home. Thereafter, he was transferred to A.O.H. on 6-10-1988. His photo was telecasted on television on ------- 1989. Till this date nobody has turned to enquire about him to take his custody. It, therefore, clearly appears that he is abandoned by his parents and relatives. He is therefore, declared as a destitute child.

Sd/-
Metropolitan Magistrate
Juvenile Court, Umerkhadi
Bombay

RELEASE DOCUMENT OF COURT COMMITTED CHILD

Social Welfare, Cultural Affairs, Sports and Tourism Department, Sachivalaya Annexe, Bombay 400 032
Bombay Children Act: 1948*
No. BCA 2376/13960-D-X: whereas the Metropolitan Magistrate, Juvenile Court,
Umerkhadi, by his order dated the 10-10-79 made under section 45 of the Bombay Children Act, 1948 (Bom. LXXI of 1948) committed the male /female child named to the care of the home, Bombay for the period ending 2008.
And whereas Mr. and Mrs. ---------- residents of (hereinafter called the custodians) have requested that the said child be given to them for care and custody and have agreed that the said male / female child will be taken care of as if s/he were their own child.
And whereas the Director of Child Welfare, Maharashtra State, Pune, has moved the State Government for release of the said male/female child to the care of the custodians after having satisfied himself about their bonafide intention and they are fit persons.
Now, therefore, in exercise of the powers conferred by subsection (1) of section 97 of the Bombay Children’s Act, 1948 and of all other powers enabling it in this behalf the Government of Maharashtra hereby order the said male /female child to be discharged from the Home and directs the authorities of the said Home to entrust him to the case of the custodians with the following instruction:

1. 1) That the custodians shall provide for the facilities of instructions to the child in his religion as envisaged in subsection (1) of section 91 of the Bombay Children Act, 1948 and shall execute a bond to that effect.
2. 2) That the custodians shall give a copy of photograph of the child to the Director of Child Welfare, Maharashtra State, Pune, while removing the child from the Institution.
3. 3) That the custodians shall send report about the progress of the child every year to the Director of Child Welfare, Maharashtra State, Pune.

By order and in the name of the Governor of Maharashtra,
Sd. ()
Under Sect. to Government of Maharashtra

To,

The Director of Child Welfare, Maharashtra State, Pune
The Divisional Social Welfare Officer, Pune
The Executive Secretary, ICSW, 175, D.N. Road, Bombay
The Superintendent , of the ------ Home, ---------- Bombay
Mr. and Mrs. (the custodians’ address)

• *Replaced by the Juvenile Justice Act, 1986

E. COURT ORDER: UNDER HINDU ADOPTION AND MAINTENANCE ACT,1956

IN THE BOMBAY CITY CIVIL COURT AT BOMBAY
Miscellaneous Petition NO. ------- of 1990
In the matter of the Hindu Adoption and Maintenance Act, 1956
AND
In the matter of the adoption of --------, a female minor under the age of 15 years.
Petitioner
V/s.
Family Service Centre, 5 Convent Street, Colaba, Bombay 400 039
Respondents:
CORAM: HIS HONOUR PRINCIPAL JUDGE SHRI ----------
Dated: 3rd day of December,1990
UPON READING the petition of ---------, the Petitioner herein declared on the 26th day of November, 1990 for permission to adopt female minor ----------, born on 5th June, 1990 and Affidavit of ----------, affirmed on the 26th day of November 1990 AND UPON READING the consent of Mrs. ---------, the wife of Petitioner AND UPON the Petitioner’s undertaking to execute Deed of Adoption by the Petitioner in favour of the said minor within one week from this date and submit the true copy of the said deed to this Honourable Court AND UNDERTAKING by the Family Service Centre, 5 Convent Street, Colaba, Bombay 400 039 to submit this Honourable Court two follow-up reports after every three months and one follow-up report after six months of the second follow-up report regarding the minor’s adjustment in the Petitioner’s family with copies of the reports to the Indian Council of Social Welfare, 175, Dr. D.N. Road, Bombay 400 001 AND UPON READING the representation of the said Indian Council of Social Welfare AND UPON HEARING --------, Advocate for the Petitioner above named AND UPON being satisfied that the conditions for valid adoption are fulfilled I DO ORDER that the Petitioner ----- is hereby given permission to adopt the said minor to himself AND I DO HEREBY CERTIFY that the date of birth of the said minor ------- is 5th June, 1990 and place of birth is Bombay and the said minor has Indian Nationality AND I DO FURTHER ORDER that the date of birth of the said minor stated above shall serve as Birth Certificate for the said minor for all purposes required by Law and no separate birth certificate shall be required for this minor AND I DO FURTHER ORDER that the Petitioner and his wife shall henceforth be considered as parents of the said minor AND I DO LASTLY ORDER that the Petitioner to pay a sum of Rs. 150/- to the said Indian Council of Social Welfare towards their cost.

Dated this 3rd day of December, 1990.
PRINCIPAL JUDGE
Advocate for the Petitioner

COURT ORDER : UNDER THE GUARDIANS AND WARDS ACT,1890

IN THE HIGH COURT OF JUDICATE ORDINARY ORIGINAL CIVIL JURISDICTION AND IN ITS GENERAL AND INHERENT JURISDICTION
Indian Guardianship Act.No. ---- of 1990.
In the matter of Guardians and Wards Act, 1890
AND
In the matter of the appointment of guardian of person of a male minor -----,inmate of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street,
Bombay 400 039
Petitioner
UPON READING the petition of --------, the Petitioner herein dated the 15th day of April, 1990 for the appointment of the Petitioner as legal guardian of male minor ------, born on the 10th day of November, 1989 AND UPON HEARING ------, Advocate for the Petitioner in support of the said petition AND UPON READING the Affidavit of --------, Social Worker of Family Service Centre, 5 Convent Street, Bombay 400 039 sworn on the 16th day of April, 1990 consenting to the appointment of the Petitioner as legal guardian of the said minor AND UPON considering the representation made by Indian Council of Social Welfare, 175, Dr.D.N.Road, Bombay 400 001 AND UPON HEARING --------, the representative of the said Indian Council AND UPON the Petitioner through his said Advocate hereby giving an undertaking to this Honourable Court to produce the said minor whenever required AND FURTHER undertaking to communicate the address of the said minor to the authorities of Family Service Centre, 5 Convent Street, Bombay 400 039 when there is a change in the address of the Petitioner by 31st day of January of every year AND FURTHER undertaking to adopt the said minor child in the event of any law being passed permitting Christians to adopt AND UPON the Petitioner through his said Advocate Further Undertaking to this Honourable Court that he will deposit Rs. 10,000/- (Rupees Twenty Five Thousand Only) in the name of the said minor child ------, born on the 10th day of November, 1989 in Unit Trust of India’s Scheme of "Children’s Gift Growth Fund 1986" for the period of -------- till the said minor attains the age of 21 years AND FURTHER Undertaking by the Petitioner that neither he nor his wife will withdraw the said or any amount from the said deposit and in the event of the said Scheme of the Unit Trust of India being for any reason discontinued the Petitioner will approach this Honourable Court taking up adoption matters for further directions in the matter of the aforesaid investment AND FURTHER Undertaking to submit to this Honourable Court every six months for two years a Follow-Up Report of the said child(alongwith his recent photograph) made or verified as correct by the Organisation which made the Home Study Report herein regarding the said minor’s moral, material progress and his adjustment in the Petitioner’s family with information of the date of arrival of the said minor to the Petitioner’s home and copies of the said reports tothe said Indian Council of Social Welfare, Bombay, I DO ORDER that the Notice under Section 11 of Guardians and Wards Act, 1890 by and the same is hereby dispensed with AND I DO FURTHER ORDER that the Petitioner ------- by and he is hereby appointed guardian without remuneration of the said minor ----------, born on the 10th day of November, 1989 whose latest photograph duly certified as such by the Advocate for the Petitioner herein and countersigned by an Officer of this Honourable Court is attached hereto and marked as Exhibit "A" and now in the custody and care of the authorities of the said Family Service Centre, 5 Convent Street, Bombay 400 039 AND I DO FURTHER ORDER that the Petitioner himself or his wife or both or any person authorised by the Petitioner are hereby given specific permission to remove the said minor from the jurisdiction of this Honourable Court and to take him away wherever and/or whenever he may desire and for that purpose make an application to the passport authorities or any other authorities to take away the said minor out of the jurisdiction of this Hon’ble Court AND I DO HEREBY LASTLY ORDER that the Petitioner herein do pay a sum of Rs. 150/- (Rupees One Hundred and Fifty Only) to the said Indian Council towards their cost of the petition.

Dated this 28th day of April 1990.
JUDGE
Sd.
Advocate for the Petitioner
Sd.
2nd Asst. Master
High Court, Bombay.

F. DEED OF ADOPTION

This Deed of Adoption is made on the 12th day of March, 1991 by me -------, aged about 46 years, permanently residing at ------------, Bombay.
WHEREAS I am a Hindu and governed under the Hindu Law and whereas I have been married since last 17 years to --------- and I have no son at all either natural or adopted and Whereas I fulfill all the conditions laid down under the Hindu Adoption and Maintenance Act, 1956, for the lawful and valid adoption and Whereas a male minor ------ born on the 10th day of June, 1990, was abandoned by his natural parent and Whereas near or far relations of this minor cannot be traced by any amount of diligence and Whereas I desired to adopt this child legally and Whereas for that purpose of Law under Section 9 (4) of the Hindu Adoption and Maintenance Act, 1956, and accordingly whereas I filed a petition with the consent of my said wife ------- in the City Civil Court at Bombay vide Miscellaneous Petition No. ----- of 1991 for getting the permission of the said Honourable Court under Section 9(4) of the Hindu Adoption and Maintenance Act, 1956, and Whereas after the said Honourable City Civil Court at Bombay was satisfied that the adoption by me will be for the said minor --------, born on the 10th day of June,1990, AND WHEREAS the said Honourable Court was further satisfied that I have fulfilled all the conditions for valid adoption by me and after so satisfying the Honourable Court was pleased to grant my petition and pass order in my favour giving the required permission to me as laid down by Law on 11th March, 1991, hereto annexed and marked as Exhibit "A" is the true copy of the certified copy of the said order of the Honourable Court granting me permission to take the said minor in adoption to myself AND WHEREAS there exists clear intention to all the persons concerned that the said minor --------, born on the 10th day of June, 1990, be transferred from his family of birth to my family AND WHEREAS to remove all possible doubts that after the said permission by the Honourable City Civil Court at Bombay, I have actually adopted this minor and the permission given to me by the Honourable City Civil Court at Bombay has been utilised by me and I hereby confirm that after signing this document nothing more is left to be done by me to complete this by me and on signing this document the adoption is complete and the permission given to me is fully utilised.
NOW THIS DEED WITNESSETH AS FOLLOWS:

a) I have taken the said minor -------, born on the 10th day of June, 1990, as my son and I have treated him as such and I declare that he shall enjoy and inherit all rights and privileges as my adopted son in accordance with the Personal Law applicable to me.

b) I further declare that I am aware that this adoption is irrevocable and I irrevocably give the status of my son to this minor.
I have made this Deed of Adoption to remove all possible doubts about having adopted this minor --------, born on -------, who is to perpetuate my line and name.
IN WITNESS whereof I have executed this Deed of Adoption on the date first aforementioned.
Signed and delivered by the within named ------ Witnesses: 1------ 2 ---------

INDEMNITY BOND

In the High Court of Judicature at Bombay
Ordinary Original Civil Jurisdiction
Miscellaneous Petition No. -------- of 198 in the matter of the Guardian and Wards Act, 1890, AND in the matter of the Appointment of Guardian of the person of minor inmate of a national of ------- residing at -----------.
Petitioner
WHEREAS by an order made by the Honourable -------------- Mr. Justice on ------ in the above matter, the Petitioner herein has been appointed the legal guardian of the minor ------- born on ------- an inmate of ------- and the said Petitioner has been permitted to take the said minor to his place of residence in -------- AND WHEREAS before taking minor out of ------ the Petitioner has undertaken to execute Bond through his duly constituted attorney in Bombay in favour of the Prothonotary and Senior Master of the High Court of Judicature at ------- for an amount of ------ to repatriate the said minor to India by air should it become necessary for any reason to do so now THIS INDENTURE OF BOND WITNESSETH that the Petitioner through his duly constituted attorney ------- in compliance of the above undertaking hereby firmly binds himself and is hereby firmly bound to pay unto the Prothonotary and Senior Master of the High Court of Judicature at ----------, his successors-in-office and assigns the sum of Rs. ------- to repatriate the said minor ------- to India by air as and when it becomes necessary for any reason to do so and further places on record that this bond shall remain effective until the said minor attains the age of majority.
Dated this ------- day of ----------
Signed and sealed and delivered by the within named ------------
In the presence of --------
Note: Normally a Bond for a sum of Rs. 15,000 is executed. The Bond is to be executed by persons taking a child out of India for the purpose of adoption.