Free Instructions - New Hampshire

Instructions for completing Department Of Health and Human Services Record Release Authorization
(NHJB-2171-FP)

Form use This form is required in adult and minor guardianships and some adoption cases when completing a background check on the proposed guardians or adoptive parents.

Top section of form ·COURT NAME: Enter the name of the county probate court where the document will be filed. (example: Belknap County Probate Court; Rockingham County Probate Court). ·CASE NAME: Enter the name of the case (example: Guardianship of John Adams; Adoption of Susan Jones). ·CASE NUMBER: Leave blank if not yet assigned by court OR fill in case number if it is known. Main section of form In the first paragraph, enter the name and complete address of the NH County Probate Court that will be receiving the records you are authorizing for release. 1. Enter your complete Name on the first line. Enter your complete Address including zip code on the second line. Also known by following names is where you enter other names you have used, such as, your maiden name, former married name, etc., on the line provided. Enter your date of birth on the line provided. List other states where you have resided as an adult and when is the place to enter the names of states in which you have lived previously. Also list the dates you lived in each state.

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Signature Section This form must be signed in the presence of a Notary Public or Justice of the Peace. They will complete the section immediately following your signature. You will sign the form on the Signature line, and date it in the appropriate space to the left. Bottom section of the form The Register of Probate will complete this section.

Review the completed form for accuracy prior to filing it with the court. If completing this form on-line, some fields may be filled in automatically based on entries in other fields. If more space is needed for any question, please attach additional sheets of paper.

NHJB-2171-FP Instructions (02/01/2008)

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