Free 53203.FH11 - Indiana

REQUEST FOR PERSONAL REFERENCE STATEMENT FOR FOSTER FAMILY HOME LICENSE APPLICANTS
State Form 53203 (R / 3-07) / CW 3419 DEPARTMENT OF CHILD SERVICES Date (month, day, year)

Name(s) of applicant(s)

The above-named applicant(s) has applied to the _____________________County Office of the Department of Child Services to become licensed as a foster parent for a child(ren) under the care and supervision of this agency. Your name has been given as a personal reference. Please complete the following questionnaire, sign and return it per the instructions at the bottom of this form within five (5) business days. A pre-addressed envelope is enclosed. Your honest responses are in the best interest of the applicant(s) and of any potential foster children who might be placed in the home. Please feel free to use the reverse side of the form or additional paper for your response. Thank you for your assistance in this very important matter. I look forward to receiving your response.
How long have you known this person(s)? In what capacity have you known this person(s)? How often do you have contact with this person(s)?

What would you say about the person(s):
Personal character (including integrity, honesty, ability to nurture)? Social behavior habits (including use of alcohol / drugs and/or other behaviors that would/would not be in the best interest of children)? Physical health? Emotional stability?

To your knowledge, has this person(s) ever been convicted of a crime? Do you think the person(s) would make an effective foster parent(s)?
Please explain your answer:

Yes Yes

No No

Would you want the person(s) to care for your children? Are you aware of any volunteer or community activities of the applicant? Does the person(s) appear to manage personal and financial affairs adequately? Would you recommend placement of a child or children in this home?
Any additional information or comments would be genuinely appreciated.

Yes Yes Yes Yes

No No No No

Signature(s) Address (number and street, city, state, and ZIP code) Printed or typed name

Date (month, day, year)

(

Telephone number (home / work / cellular)

)

PLEASE RETURN TO: ATTENTION (Family Case Manager / Foster Care Licensing Worker):