REQUEST FOR CERTIFICATE OF ADOPTION OR TERMINATION OF PARENTAL RIGHTS I request a certificate from the court to prove that my parental rights and responsibilities have been terminated as to the child named below. 1. 2. My full name: My parental rights were terminated because the child was adopted. in a separate proceeding (not related to an adoption). Case number (if known): The adoption/termination proceeding took place in (city where court is located) 5. 6. Child's full name before adoption or termination: If child was adopted, child's full name after adoption: . . . 3. 4. I understand that I must present photo identification when I give this request to the court. If I am mailing the request to the court, I understand that it must be notarized below. Signature Mailing Address City State Daytime Telephone Number Notarization (only required if request is mailed to court) The individual making this request, on , appeared before me and presented photo identification in the form of a valid showing him or her to be the person named above. Notary Public My commission expires: Page 1 of 2 P-440 (10/97)(cs ­ duplex) REQUEST FOR CERTIFICATE Adoption Rule 16(f) American LegalNet, Inc. www.USCourtForms.com Zip Instructions If you need proof that your rights and responsibilities as a parent of a child have been ended by a court order (either in a termination proceeding or an adoption proceeding), you can ask the court for a certificate confirming that your parental rights have been terminated. 1. Fill out the request form on the other side of this sheet. a. If your rights ended because the child was adopted, you will need to provide either the case number for the adoption or the new name the child was given during the adoption. Adoption cases are indexed by the child's new name, so the court will need either that name or the case number to find your case file. If your parental rights were terminated in a separate proceeding (not related to an adoption), the case will be indexed by the child's original name, so you will not need to know whether the child has been given a new name. b. 2. Take your request to the court that issued the order terminating your rights or granting the adoption. The files on these matters are confidential (not open to the public), so the court will need proof that you are the parent whose rights were terminated before the court will give you this certificate. You will need to bring photo identification with you to the court. Note that in Anchorage and Fairbanks you will need to go to the Probate Office rather than the main clerk's office to get adoption records. If you do not live in the same community as the court that issued the order, you can mail your request to the court. If you mail in your request, you will need to establish proof of your identity by taking your photo identification to a notary public and having the notary fill out the "Notarization" section at the bottom of the request form. 3. The court will not charge you a fee for requesting this certificate. Page 2 of 2 P-440 (10/97)(cs ­ duplex) REQUEST FOR CERTIFICATE Adoption Rule 16(f) American LegalNet, Inc. www.USCourtForms.com