Free CCCO 0018 10-05-07.pmd - Illinois

Petition for Appointment of a Confidential Intermediary

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(10/05/07) CCCO 0018 A

IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS In the Matter of the Petition of

______________________________________________,
For appointment of Confidential Intermediary

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No. ________________________________

PETITION FOR APPOINTMENT OF A CONFIDENTIAL INTERMEDIARY (6002)
Comes now ___________________________________________ petitioning this Court for the appointment of a Confidential Intermediary pursuant to 750 ILCS 50/18.3a and in support of this petition states as follows: 1. I am (select one)
an adopted person 21 years of age or over. a "surrendered person" 21 years of age or over (Note: A "surrendered person" is a person who was never adopted but whose birth parents' rights were surrendered or terminated). an adoptive parent of an adopted or surrendered person under the age of 21. Please complete the following information, if known:

Date of adoption: Adoption case number:

__________________________ __________________________

a legal guardian of an adopted or surrendered person under the age of 21. Please attach a copy of the order appointing the Petitioner the legal guardian of the adopted or surrendered person. a birth parent of a surrendered person of 21 years of age or over. an adult child of a deceased adopted or surrendered person. Please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person. a legal guardian of a deceased adopted or surrendered person. Please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person. a surviving spouse of a deceased adopted or surrendered person. Please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person. an adult birth sibling of an adopted or surrendered person whose common birth parent is deceased and whose adopted or surrendered birth sibling is 21 years of age or over. Please attach documents establishing the relationship between the Petitioner and the deceased birth parent as well as a copy of the death certificate for the deceased birth parent.
(OVER)

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(10/05/07) CCCO 0018 B

an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over. Please attach copies of the deceased birth parent's death certificate and all documents establishing the relationship between Petitioner and the deceased birth parent. 2. That __________________________________________ is an adopted or surrendered person having a date
(Name of adopted or surrendered person or child's name at birth)

of birth of ______________________, and on the date of filing this Petition said adopted or surrendered person is _______ years of age. Since the date of my adoption or date that I became a surrendered person, my name has been legally changed by marriage (please attach a copy of a marriage certificate) or by legal change of name (please attach a certified copy of order changing name). Strike if not applicable. 3.

____________________________________ was adopted by _________________________________
(Name of adopted person)

____________________________________ on or about ____________________________________ in ______________________________ County, Illinois and named ______________________________.
4. That the Petitioner seeks the appointment of Confidential Intermediary for the purpose of (select all that apply): exchanging medical information with one or more mutually consenting biological relatives of the adopted or surrendered person; and/or obtaining identifying information about one or more mutually consenting biological relatives of the adopted or surrendered person; and/or arranging contact with one or more mutually consenting biological relatives of the adopted or surrendered person; and/or 5. The Petitioner seeks the following biological relative(s) (select all that apply): any/all living birth relatives 21 years of age or over birth son(s) or daughter(s) 21 years of age or over birth mother birth father birth sibling 21 years of age or over other person 21 years of age or over (please identify): 6. If the Petitioner is: an adult child, adoptive parent, legal guardian or surviving spouse of a deceased adopted or surrendered person (strike as applicable); or an adult birth sibling of an adopted or surrendered person whose common birth parent is deceased and whose adopted or surrendered birth sibling is 21 years of age or over; or an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over,

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(10/05/07) CCCO 0018 C

disclosure of the requested information is of greater benefit than nondisclosure because: Please explain in detail why you are filing the petition. Attach additional pages or documents as needed.

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
7. The Petitioner has been entered into the Illinois Adoption Registry and Medical Information Exchange as evidenced by the attached verification of registration letter.

NOTICE Except as stated below, the Petitioner understands that the appointed Confidential Intermediary will not have access to the following: personal health information protected by the Standards for Privacy of Individually Identifiable Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); medical records; financial records; credit records; banking records; home studies; attorney's records; or other personal records. The Petitioner also understands the public or private adoption agency shall only disclose to the Confidential Intermediary the full name, the date of birth, place of birth, last known address and last known telephone number of the sought after relative. If the Petitioner is an adult adopted person or the adoptive parent of a minor and if the Petitioner has signed a written authorization to disclose personal medical information, adoption agency disclosing information a Confidential Intermediary shall disclose available medical information about the adopted person from birth through adoption (see 750 ILCS 50/18.3a (g)). WHEREFORE, the Petitioner prays that this Court appoint a Confidential Intermediary pursuant to the Adoption Act at 750 ILCS 50/18.3a, and for such other relief as may be necessary.

Respectfully submitted,

Dated: __________________________, __________

________________________________________
Petitioner

CERTIFICATION Under penalties for perjury as provided in Section 1-109 of the Code of Civil Procedure the undersigned states that the foregoing facts contained in the Petition for Appointment of a Confidential Intermediary are true based upon personal knowledge and belief.

________________________________________
Petitioner
(OVER)

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(10/05/07) CCCO 0018 D

STATE OF ILLINOIS COUNTY OF COOK

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ss:

I, ____________________________________________, a duly authorized Notary Public in and for State of ____________________________, County of _________________________ do hereby state that on the ____________ day of ___________________________, __________ the aforesaid person appeared before me and affixed his/her signature to this document and that I am personally acquainted with the named individual s/he having established his/her identity in the following manner:

________________________________________________________________________________________ ________________________________________________________________________________________
I have attached legible copies of the documents shown to me in order to establish his/her identity to the original petition to be filed with this court.

(S e a l)

_______________________________________
(Notary Public)

Commission Expires: ____________________, __________

Note: The Petition must be certified by the Petitioner and notarized to establish the Petitioner's identity.

Name: __________________________________________ Address: ________________________________________ City/State/Zip: ___________________________________ Telephone: ______________________________________

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS