Court Opinions

BIRTH PARENT REGISTRATION IDENTIFICATION (Insert all known information) I, ....., state that I am the ...... (mother or father) of the following child:

Child's original name: ..... (first) ..... (middle) ..... (last), ..... (hour of birth), ..... (date of birth), ..... (city and state of birth), ..... (name of hospital). Father's full name: ...... (first) ...... (middle) ..... (last), ..... (date of birth), ..... (city and state of birth). Name of mother inserted on birth certificate: ..... (first) ..... (middle) ..... (last), ..... (race), ..... (date of birth), ...... (city and state of birth). That I surrendered my child to: ............. (name of agency), ..... (city and state of agency), ..... (approximate date child surrendered). That I placed my child by private adoption: ..... (date), ...... (city and state). Name of adoptive parents, if known: ......

Other identifying information: ..... ........................ (Signature of parent) ............ ........................

(date) (printed name of parent)

(b) The form of the Adopted Person Registration Identification shall be substantially as follows:

ADOPTED PERSON REGISTRATION IDENTIFICATION (Insert all known information) I, ....., state the following:

Adopted Person's present name: ..... (first) ..... (middle) ..... (last). Adopted Person's name at birth (if known): ..... (first) ..... (middle) ..... (last), ..... (birth date), ..... (city and state of birth), ...... (sex), ..... (race). Name of adoptive father: ..... (first) ..... (middle) ..... (last), ..... (race). Maiden name of adoptive mother: ..... (first) ..... (middle) ..... (last), ..... (race). Name of birth mother (if known): ..... (first) ..... (middle) ..... (last), ..... (race). Name of birth father (if known): ..... (first) ..... (middle) ..... (last), ..... (race). Name(s) at birth of sibling(s) having a common birth parent with adoptee (if known): ..... (first) ..... (middle) ..... (last), ..... (race), and name of common birth parent: ..... (first) ..... (middle) ..... (last), ..... (race). I was adopted through: ..... (name of agency).

I was adopted privately: ..... (state "yes" if known).

I was adopted in ..... (city and state), ..... (approximate date). Other identifying information: ............. ...................... (signature of adoptee) ........... .........................

(date) (printed name of adoptee)

SURRENDERED PERSON REGISTRATION IDENTIFICATION (Insert all known information) I, ....., state the following:

Surrendered Person's present name: ..... (first) ..... (middle) ..... (last). Surrendered Person's name at birth (if known): ..... (first) ..... (middle) ..... (last), .....(birth date), ..... (city and state of birth), ...... (sex), ..... (race). Name of guardian father: ..... (first) ..... (middle) ..... (last), ..... (race). Maiden name of guardian mother: ..... (first) ..... (middle) ..... (last), ..... (race). Name of birth mother (if known): ..... (first) ..... (middle) ..... (last) ..... (race). Name of birth father (if known): ..... (first) ..... (middle) ..... (last), .....(race). Name(s) at birth of sibling(s) having a common birth parent with surrendered person (if known): ..... (first) ..... (middle) ..... (last), ..... (race), and name of common birth parent: ..... (first) ..... (middle) ..... (last), ..... (race). I was surrendered for adoption to: ..... (name of agency).

I was surrendered for adoption in ..... (city and state), ..... (approximate date). Other identifying information: ............ ................................ (signature of surrendered person) ............ ......................

(date) (printed name of person

surrendered for adoption)

(c-3) The form of the Registration Identification Form for Surviving Relatives of Deceased Birth Parents shall be substantially as follows:

REGISTRATION IDENTIFICATION FORM FOR SURVIVING RELATIVES OF DECEASED BIRTH PARENTS (Insert all known information) I, ....., state the following:

Name of deceased birth parent at time of surrender:

Deceased birth parent's date of birth:

Deceased birth parent's date of death:

Adopted or surrendered person's name at birth (if known): .....(first) ..... (middle) ..... (last), .....(birth date), ..... (city and state of birth), ...... (sex), ..... (race). My relationship to the adopted or surrendered person (check one): (birth parent's non-surrendered child) (birth parent's sister) (birth parent's brother).

If you are a non-surrendered child of the birth parent, provide name(s) at birth and age(s) of non-surrendered siblings having a common parent with the birth parent. If more than one sibling, please give information requested below on reverse side of this form. If you are a sibling or parent of the birth parent, provide name(s) at birth and age(s) of the sibling(s) of the birth parent. If more than one sibling, please give information requested below on reverse side of this form.

Name (First) ..... (middle) ..... (last), .....(birth date), ..... (city and state of birth), ...... (sex), ..... (race). Name(s) of common parent(s) (first) ..... (middle) ..... (last), .....(race), (first) ..... (middle) ..... (last), .....(race). My birth sibling/child of my brother/child of my sister/ was surrendered for adoption to ..... (name of agency) City and state of agency ..... Date .....(approximate) Other identifying information ..... (Please note that you must: (i) be at least 21 years of age to register; (ii) submit with your registration a certified copy of the birth parent's birth certificate; (iii) submit a certified copy of the birth parent's death certificate; and (iv) if you are a non-surrendered birth sibling or a sibling of the deceased birth parent, also submit a certified copy of your birth certificate with this registration. No application from a surviving relative of a deceased birth parent can be accepted if the birth parent filed a Denial of Information Exchange prior to his or her death.) ................................ (signature of birth parent's surviving relative)

............ ............

(date) (printed name of birth

parent's surviving relative)

(c-5) The form of the Registration Identification Form for Surviving Relatives of Deceased Adopted or Surrendered Persons shall be substantially as follows:

REGISTRATION IDENTIFICATION FORM FOR SURVIVING RELATIVES OF DECEASED ADOPTED OR SURRENDERED PERSONS (Insert all known information) I, ....., state the following:

Adopted or surrendered person's name at birth (if known): (first) ..... (middle) ..... (last), .....(birth date), ..... (city and state of birth), ...... (sex), ..... (race). Adopted or surrendered person's date of death:

My relationship to the deceased adopted or surrendered person(check one): (adoptive mother) (adoptive father) (adult child) (surviving spouse).

If you are an adult child or surviving spouse of the adopted or surrendered person, provide name(s) at birth and age(s) of the children of the adopted or surrendered person. If the adopted or surrendered person had more than one child, please give information requested below on reverse side of this form. Name (first) ..... (middle) ..... (last), .....(birth date), ..... (city and state of birth), ...... (sex), ..... (race). Name(s) of common parent(s) (first) ..... (middle) ..... (last), .....(race), (first) ..... (middle) ..... (last), .....(race). My child/parent/deceased spouse was surrendered for adoption to .....(name of agency) City and state of agency ..... Date ..... (approximate) Other identifying information ..... (Please note that you must: (i) be at least 21 years of age to register; (ii) submit with your registration a certified copy of the adopted or surrendered person's death certificate; (iii) if you are the child of a deceased adopted or surrendered person, also submit a certified copy of your birth certificate with this registration; and (iv) if you are the surviving wife or husband of a deceased adopted or surrendered person, also submit a copy of your marriage certificate with this registration. No application from a surviving relative of a deceased adopted or surrendered person can be accepted if the adopted or surrendered person filed a Denial of Information Exchange prior to his or her death.) ................................ (signature of adopted or surrendered person's surviving relative)

............ ............

(date) (printed name of adopted

person's surviving relative)

(d) The form of the Information Exchange Authorization shall be substantially as follows:

INFORMATION EXCHANGE AUTHORIZATION I, ....., state that I am the person who completed the Registration Identification; that I am of the age of ..... years; that I hereby authorize the Department of Public Health to give to the following person(s) (birth mother ) (birth father) (birth sibling) (adopted or surrendered person ) (adoptive mother) (adoptive father) (legal guardian of an adopted or surrendered person) (birth aunt) (birth uncle) (adult child of a deceased adopted or surrendered person) (surviving spouse of a deceased adopted or surrendered person) (all eligible relatives) the following (please check the information authorized for exchange):

[ ] 1. Only my name and last known address.

[ ] 2. A copy of my Illinois Adoption Registry Application. [ ] 3. A copy of the original certificate of live birth. [ ] 4. A copy of my completed medical questionnaire. I am fully aware that I can only be supplied with information about an individual or individuals who have duly executed an Information Exchange Authorization that has not been revoked; that I can be contacted by writing to: ..... (own name or name of person to contact) (address) (phone number).

Dated (insert date).

.............. (signature)

(e) The form of the Denial of Information Exchange shall be substantially as follows:

DENIAL OF INFORMATION EXCHANGE I, ....., state that I am the person who completed the Registration Identification; that I am of the age of ..... years; that I hereby instruct the Department of Public Health not to give any identifying information about me to the following person(s) (birth mother) (birth father) (birth sibling)(adopted or surrendered person)(adoptive mother) (adoptive father)(legal guardian of an adopted or surrendered person)(birth aunt)(birth uncle)(adult child of a deceased adopted or surrendered person) (surviving spouse of a deceased adopted or surrendered person) (all eligible relatives) ; that I do not wish to be contacted.

Dated (insert date).

............... (signature)

(f) The Information Exchange Authorization and the Denial of Information Exchange shall be acknowledged by the birth parent, birth sibling, adopted or surrendered person, adoptive parent, or legal guardian before a notary public, in form substantially as follows:

State of ..............

County of .............

I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that ............... personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (he or she) signed such certificate as (his or her) free and voluntary act and that the statements in such certificate are true.

Given under my hand and notarial seal on (insert date). ......................... (signature)

(g) When the execution of an Information Exchange Authorization or a Denial of Information Exchange is acknowledged before a representative of an agency, such representative shall have his signature on said Certificate acknowledged before a notary public, in form substantially as follows:

State of..........

County of.........

I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that ..... personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (he or she) signed such certificate as (his or her) free and voluntary act and that the statements in such certificate are true.

Given under my hand and notarial seal on (insert date). ....................... (signature)

(h) When an Illinois Adoption Registry Application, Information Exchange Authorization or a Denial of Information Exchange is executed in a foreign country, the execution of such document shall be acknowledged or affirmed before an officer of the United States consular services.

(i) If the person signing an Information Exchange Authorization or a Denial of Information is in the military service of the United States, the execution of such document may be acknowledged before a commissioned officer and the signature of such officer on such certificate shall be verified or acknowledged before a notary public or by such other procedure as is then in effect for such division or branch of the armed forces.

(j) The Department shall modify these forms as necessary to implement the provisions of this amendatory Act of 1999 including creating Registration Identification Forms for non-surrendered birth siblings, adoptive parents and legal guardians.

(Source: P.A. 93-189, eff. 1-1-04; 94-173, eff. 1-1-06.)

Last modified: April 7, 2006

Court Opinions

State Laws

US Code

US Constitution

Illinois Adoption Act - 750 ILCS 50, Section 18.2

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