MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION STATEMENT OF LEGAL RISK
CHILD’S NAME:	DATE:
PROSPECTIVE ADOPTIVE PARENT:
PROSPECTIVE ADOPTIVE PARENT:
CHILDREN’S SERVICE WORKER:
CHILDREN’S SERVICE SUPERVISOR I:
STATEMENT OF LEGAL RISK:
I/We,	the prospective adoptive parents of
, have been informed and understand there is a legal
risk involved with this child which needs to reconcile prior to the adoption being finalized. Furthermore, we have been informed and understand if the legal risks are not resolved, it may become necessary to remove the child from our home. We understand only the juvenile court has the final authority to approve the adoption of a specific child by a specific family. We understand being selected as an adoptive family through the adoption staffing process does not guarantee subsidy funding. We understand should the court approve the adoption of this child to another family, we may not receive any compensation for funds paid by us to facilitate the adoption.
Specifics regarding visitation with birth parents or others specific to this placement should be explained here:
Prospective Adoptive Parent’s Signature :	Date:
Prospective Adoptive Parent’s Signature :	Date:
Children’s Service Worker Signature :	Date:
Children’s Service Supervisor I Signature:	Date: