Free 47897.pdf - Indiana

INDIANA ADOPTION HISTORY REGISTRATION - NONIDENTIFYING INFORMATION CONSENT
State Form 47897 (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)
Adult Adoptee Adoptive Parent Birth 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)

I am the:

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

Part Five - 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