Petition for Order Directing Department of Public Health to Issue Original Birth Certificate PC-607 REV. 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) RECEIVED: Instructions: 1) An adult adopted person whose adoption was finalized prior to October 1, 1983, or such person's adult child or grandchild, may use this form to petition the court for an order directing the Department of Public Health to issue an uncertified copy of an original birth certificate to the petitioner. For the court to issue the order, each birth parent named on the original birth certificate must: a) have consented to the release of identifying information in accordance with C.G.S. sections 45a- 751 to 45a-751b, b) be deceased, OR c) a legal representative or guardian ad litem for the birth parent must have consented to the release of identifying information in accordance with C.G.S. section 45a-753. If the adopted person is deceased, the petition may be filed by a biological parent, an adult biological sibling or an adult descendant of the adopted person. Supporting evidence should be filed with the petition. 2) The petition should be filed in the Probate Court that finalized the adoption or appointed a guardian ad litem in accordance with C.G.S. section 45a-753. 3) For more information, see C.G.S. sections 45a-743 and 45a-751 to 45a-753. 4) Type or print the form in ink. Use Second Sheet, PC-180, or an additional sheet, if more space is needed. District Number Date of Adoption Decree Date and Place of Birth of Adopted Person Probate Court Name In the Matter of (List name and address.) An adult adopted person. Petitioner (Include address if not the adopted person.) Relationship to the Adopted Person if Adopted Person is Not the Petitioner The petitioner represents that: The adoption for the adult for whom an original birth certificate is being requested was finalized by this court after January 1, 1944 and before October 1, 1983. The petitioner is the adult adopted person the adult child or grandchild of the adult adopted person, who is living at the date of this petition; OR The adult adopted person has died, and the petitioner is the adopted person's adult biological parent adult biological sibling or adult biological descendant, including legally adopted descendants AND the birth parent (s) named on the birth certificate has consented to the release of identifying information in accordance with C.G.S. sections 45a-751 to 45a-751b, inclusive; the birth parent(s) is deceased; OR the birth parent(s) cannot be located or appears to be incompetent, and the legal representative of the birth parent or the guardian ad litem appointed by the Probate Court has consented to the release of identifying information in accordance with C.G.S. section 45a-753. Petition for Order Directing Department of Public Health to Issue Original Birth Certificate PC-607 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Order Directing Department of Public Health to Issue Original Birth Certificate PC-607 REV. 7/15 CONNECTICUT PROBATE COURTS RECORDED (CONFIDENTIAL) WHEREFORE, the petitioner requests that the court order the Department of Public Health to issue an uncertified original birth certificate for the adult adopted person to the petitioner. Signature of Petitioner Type or Print Name Date Petition for Order Directing Department of Public Health to Issue Original Birth Certificate PC-607 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com