Free Form DOH-4455 - Adoption Information Registry Birth Parent Registration Form - New York

NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section

Adoption Information Registry Birth Parent Registration Form
Registry # Date

This form is to be completed by birth parents who consent to the adoption or who execute an instrument of surrender. It is used to register a birth parent's agreement or non-agreement to the release of the birth parent's name and address by the Adoption Registry to the adoptee (the adopted child). This identifying information will be given to the adopted child only when the child reaches at least eighteen years of age and voluntarily registers with the Adoption Registry. This form may also be used at any time after the adoption to agree to the release of identifying information, to withdraw your agreement or to update your contact information. Instructions for the birth parents, adoption agencies, attorneys, courts and the NYC Department of Health and Mental Hygiene are on page 2.

FOR OFFICIAL NYS USE ONLY

Print Form

1. Birth Parent Information:
Check one: Name of birth parent First Name: Current Last Name:

Birth Mother

c

Birth Father

c

Date of your birth: Middle Name: Maiden Last Name:

MM/DD/YYYY

Contact Information: Mailing address Street:
State: Email address: ZIP:

(If Applicable)

City/Town:

Phone: (

)

-

2. Adoptee Information:
Name given to child at birth First Name: Last Name: Town, city or village of birth of adoptee: Middle Name: Date of Birth: , New York State.
MM / DD / YYYY

3. Agency Information:
Name of Adoption Agency or Attorney if private adoption:

4. Birth Parent Statement:

Name of Court:

c c

I have read the Notice to Birth Parents on the reverse side of this form and I understand that if I agree to the release of identifying information the adoptee can be given my name and known address and that I will not be notified when the information is released. Further, I swear or affirm under penalty of perjury that all of the information provided on this application is true and accurate to the best of my knowledge and belief.

Yes, I agree that my name and address can be given to the adopted child if he or she registers with the Adoption Information Registry on or after his or her eighteenth birthday.

STATE OF COUNTY OF

No, I do not wish my name and address to be given to the adopted child.

h e SS: g

If you change your mind after submitting this form, please complete a new form, checking either Yes or No, have the form notarized and send it to the Adoption Registry. The form with the most recent date will be kept on file.

Subscribed and sworn to (affirmed) before me this

4

Signature of Applicant
DOH-4455 (10/2008)

4

day of Signature of Notary Public

,

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NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section

Adoption Information Registry Birth Parent Registration Form

This form was developed in accordance with the provisions of Public Health Law section 4138-c(10).

Notice to Birth Parents
Do not complete this form for children born or adopted outside of New York State. The completed form will be submitted to the Court by the agency or attorney handling the adoption. The Court will send it to the Adoption Registry. This form allows you to choose whether or not you would like the Adoption Registry to provide your name and address ("identifying information") to the adopted child. If you agree to the release of this information, the contact information will be provided to the child only if he or she registers with the Adoption Registry. The child will be able to register once he or she has reached at least eighteen years of age. Checking Yes in item 4 on this form is not the same as giving consent to adoption or surrender. Whether you check Yes or No, your consent to or acknowledgment of the adoption or surrender will still be legal. If you do not check either Yes or No we will treat your answer as No unless we already have a completed form from you on file. In that case, your previous choice will be retained and only your contact information will be updated. You will not be notified if or when the Adoption Registry gives your information to the adopted child. It will be up to the adopted child whether or not he or she will request information or contact you. If both birth parents consented to the adoption or executed a surrender instrument, then each must complete one of these forms. If either parent does not agree to the release of identifying information or later changes his or her mind and revokes agreement to the release of identifying information, the Adoption Registry will not release the name and address of either parent to the adopted child. If you change your mind in the future you can complete a new form and agree to the release of identifying information or cancel your agreement by checking either Yes or No, having the form notarized and submitting the new form to the NYS Department of Health, Adoption Information Registry, P.O. Box 2602, Albany, NY 12220-2602. The adopted child will receive the most current name and address that you have on file with the Adoption Registry. To make sure the child gets your current information, it is your responsibility to notify the Adoption Registry, in writing, if you change your name, address or other information. You may use this form to notify the registry of changes in your contact information. You can file medical information updates with the Adoption Registry. Medical information must be submitted on your medical care provider's letterhead and include: medical care provider's name, address, telephone number and signature. Further information about the services of the Adoption Registry and forms you can download can be found at http://www.nyhealth.gov/vital_records/adoption.htm and http://www.nycourts.gov/forms/familycourt/adoption.shtml

Adoption Agencies & Attorneys
For a child born in New York State, this form must be completed by the birth parent at the time the birth parent is either executing or acknowledging a consent to adoption pursuant to section 115-b of the Domestic Relations Law or is executing a surrender instrument pursuant to sections 383-c or 384 of the Social Services Law. Completed forms must be filed with the court of adoption with the consent or instrument of surrender.

Court of Adoption
For a child born in New York State, this form must be completed by each birth parent at the time such birth parent is executing or acknowledging a consent to adoption or is executing a surrender instrument for the relinquishment of the child named in this form. Send the Report of Adoption (DOH-1928) or, for New York City, Notification of Order of Adoption (VR-47) and a copy of this form to:

Adoptee born in New York City:
NYC Department of Health & Mental Hygiene Office of Vital Records 125 Worth St., Rm. 133, CN4 New York, NY 10013

Adoptee born elsewhere in New York State:
NYS Department of Health Vital Records Birth Amendment Unit P.O. Box 2602 Albany, NY 12220-2602

NYC Department of Health & Mental Hygiene
Send copies of this form, the Notification of Order of Adoption, the original birth certificate and the amended birth certificate to: NYS Department of Health, Adoption Information Registry, P.O. Box 2602, Albany, NY 12220-2602
DOH-4455 (10/2008)

CLEAR FORM
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