Free 47896.pdf - Indiana

INDIANA ADOPTION HISTORY REGISTRATION - IDENTIFYING INFORMATION CONSENT
State Form 47896 (R3/6-05)

INSTRUCTIONS: All information, except the written signature(s), must be typed or clearly printed in black ink. Agency Use Only

CONFIDENTIAL INFORMATION per IC 31-19-19-1

All parts of this form must be completed before the Consent Form can be filed.
Part One - Your Filing Status (Please do not check more than one box)

I am the:

Adult Adoptee Birth Parent

Adoptive Parent Pre-adoptive Sibling

Spouse or Relative of a Deceased Adoptee (if the relationship existed at the time of the adoptee's death) Spouse or Relative of a Deceased Birth Parent (if the relationship existed at the time of the birth parent's death)

Part Two - Individual Completing This Consent Form
Name Date of Birth Mailing Address

Telephone Number, including Area Code Please Note: A photocopy of signature identification must accompany this form (e.g., driver's license, Social Security card).

Part Three - Child's Birth Information
Child's Birth Name Child's Date of Birth Child's Place of Birth Full Name of Birth Father* Full Name of Birth Mother (include maiden name)*
*If deceased, submit a copy of the death certificate.

Child's Sex

Part Four - Adoptee or Adoptive Parents Only
Child's Name after Adoption Child's Date of Birth Child's Place of Birth Full Name of Adoptive Father Full Name of Adoptive Mother

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Part Five - Identifying Information Consent/Restriction

Information may be released to (please check appropriate box[es]):
Adult Adoptee Birth Parent Adoptive Parent Pre-adoptive Sibling

Spouse or Relative of a Deceased Adoptee (if the relationship existed at the time of the adoptee's death) Spouse or Relative of a Deceased Birth Parent (if the relationship existed at the time of the birth parent's death)

Part Six - Affirmation I affirm, under the penalties for perjury, that these representations are true to the best of my knowledge and belief, and that I am qualified to receive adoption history information under I.C. 31-19-18-2.
(Date) (Written Signature)

Please return this form to: Indiana Adoption History Registry Indiana State Department of Health Vital Records Division, B-4 2 North Meridian Street Indianapolis, Indiana 46204

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