PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge NAME:_____________________________________________________________________ Case No: ______________________ AUTHORIZATION FOR RELEASE OF INFORMATION (To be completed by the prospective adoptive parent and any person 18 or older who resides with the prospective adoptive parent) I, __________________________________, of _______________________________________________ (Applicant) (Address) do hereby authorize the Wood County Sheriff's Office or other authorized law enforcement agency to conduct a criminal records check on me through the superintendent of the Ohio BCII and through local records and to release any available criminal background check records to the Wood County Probate Court for purposes of pending adoption proceedings. This request is authorized pursuant to Ohio Revised Code 2151.86(A). I further authorize the Wood County Department of Job and Family Services to conduct and prepare a summary report of a search of the statewide automated child welfare information system (SACWIS) established in section 5101.13 of the Ohio Revised Code and a report of a check of a central registry of another state if required by statute and to release all information contained within said registries to the Wood County Probate Court for purposes of pending adoption proceedings. This request is authorized pursuant to Ohio Revised Code 3107.033 and 3107.034. I understand a criminal records check will be requested by the Wood County Probate Court on my behalf from the Wood County Sheriff's Office and a SACWIS search will be requested from Job and Family Services. I further understand I am responsible for scheduling and obtaining a BCI background check and, if I have lived outside Ohio in the last five years, an FBI background check at my own expense which I will forward to the Court. ____________________________________ Signature Date of Birth Social Security Number Previous Address Maiden Name Spouse's Name Name of former Spouse(s) Name(s) of Child(ren) Ages of Children Duration of Residence in Ohio A.K.A. ______________________________________ Witness --------------------------------------------------------------------------------TO BE COMPLETED BY EACH AGENCY: Please check appropriate space and sign. If a record is located, attach record/information to this form. Record Located Record Located No Record Located Wood County Job and Family Services/Children's Services No Record Located Wood County Sheriff's Department FORM 19.12 - AUTHORIZATION FOR RELEASE OF INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com