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ADOPT-216

Verification of Compliance with Hague  
Adoption Convention Attachment

(Attach to Adoption Order (form ADOPT-215) in cases proceeding under 
the Hague Adoption Convention.)

1

Determination of Application of Hague Adoption Convention  
(to be completed by adopting parent(s)):

a. 

If applicable, please state the permanent address outside the United 
States of the adopting parent(s): 

b.

c.

d.

e.

f.

Superior Court of California, County of

Will you be moving the child to permanently reside in another  
country?  

Yes

No

If your answer to 1(b) is yes, what is the name of the other country?

If your answer to 1(b) is yes, when will the move occur?

Court fills in case number when form is filed.

Case Number:

Has the child lived in any other country since his/her birth? 

Yes

No

If your answer to 1(e) is yes, please indicate the country and the length of time the child resided there. 
(country): 
(length of time resided in country): 

g.

What is the child's citizenship?

h. Please state date(s) for any contact between the prospective adoptive parent(s) and the child's birth parent(s) or 

any other person who has had care of the child and describe the contact:

i. Please state the amount and purpose of any payments made by the adopting parent(s) to the birth parent(s)  

or any other person who has had care of the child:

2

Court Findings (to be completed by the judge)

The court finds as follows:

The Hague Adoption Convention applies to this adoption.

All parental rights have been terminated and the child has been declared free from the custody and control of his 
or her parents; thus, the child is adoptable. (Convention, art. 4(a).)

Judicial Council of California,  www.courts.ca.gov   
New July 1, 2013, Mandatory Form  
Family Code, §§ 8900, 8900.5, 8901, 8902, 8903,  
8904, 8905, 8908, 8910, 8911, 8912, 8919, 8924,  
8925; 22 Code of Federal Regulations Part 96, § 97.3; 
Hague Adoption Convention 

Verification of Compliance with 
Hague Adoption Convention Attachment

ADOPT-216, Page 1 of 2

Your name:

Case Number:

By clear and convincing evidence, an intercountry adoption is in the best interest of  the child. (Convention, art.  
4(b).)

The adoption services provider meets the requirements of 22 C.F.R. (Code of Federal Regulations) part 96.

Court Verifications (to be completed by the judge)

3

The court verifies that the agency has met the substantive regulatory requirements of 22 C.F.R. § 97.3(a)–(k) in the 
following categories:

Preparation of child background study (Convention, art. 16(1)(a); 22 C.F.R. § 97.3(a));

Transmission of child data to foreign authorized entity (Convention, art. 16(2); 22 § C.F.R. 97.3(b));

Reasonable efforts to find domestic placement (Convention, art. 4(b); 22 C.F.R. § 97.3(c));

Preparation and transmission of home study (Convention, art. 15; 22 C.F.R. § 97.3(d));

Authorization for the child to enter the receiving country (Convention, art. 5; 22 C.F.R. § 97.3(e));

Consent to the adoption/custody by foreign authorized entity (name of entity):  
(Convention, art. 17; 22 C.F.R. § 97.3(f));

Guardian/parent counseling and consent (specify):   
(Convention, art. 4(d); 22 C.F.R. § 97.3(g));

Child counseling and consent (if applicable)(specify):    
(22 C.F.R. § 97.3(h));

The agency and the Central Authority of the receiving country, as defined in Family Code section 8900.5(c),  
(name of receiving country):                                                                                                     
(name of central authority):     
have both signed Placement Adoption Papers (22 C.F.R. § 97.3(i));

The agency has taken all steps to ensure the secure transfer of the child, including obtaining permission for  
the child to leave the United States (Convention, arts. 18 & 19; 22 C.F.R. § 97.3(i));

The agency has taken all steps to keep the Central Authority of the receiving country informed about the  
adoption process, as well as the progress of the placement if a probationary period is required (Convention, art. 
20; 22 C.F.R. § 97.3(i));

Proper observance of the “no-contact” rule, if applicable (22 C.F.R. § 97.3(j));

That no improper financial or other gain was derived (22 C.F.R. § 97.3(k)).

Court Orders

4

The court grants

Final adoption order.

Final custody decree.

Date:

New July 1, 2013

Judge (or Judicial Officer)

For your protection and privacy, please press the Clear 
This Form button after you have printed the form.

Verification of Compliance with  
Hague Adoption Convention Attachment

ADOPT-216, Page 2 of 2

Verification of Compliance with Hague Adoption Convention Attachment

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About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 37
Average fields per page: 18
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Verification of Compliance with Hague Adoption Convention Attachment

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02