Form 109 (2/07) FILM The Family Court of the State of Delaware For New Castle Kent Sussex County AFFIDAVIT REGARDING THE RELEASE OF INFORMATION IN ADOPTION Title 13, Chapter 9, Subchapter III of the Delaware Code provides a system of affidavits to deny or consent to the release of identifying information upon the request from another party to the adoption. In accordance with the provisions of this legislation, I, Name: First Middle Last (Maiden and Marriage) living at Street, City, a birth parent of State Zip Code born on (Name, if known) (Check only one) authorize Family Court to provide a copy of the adoptee's original birth certificate, and authorize the Family Court, Department of Services for Children, Youth and Their Families, or licensed agency handling the termination of parental rights or adoption procedures to release identifying information, to the adopted individual after age 18, or the adoptive parent(s) before the child's 18th birthday. deny the release of any identifying information regarding myself to the adult adoptee or any other person an adoptive parent of the minor child born (Check only one) authorize the release of my name and address to the birth parent(s) of the child until the child turns 18. deny release of my name and address to the birth parents of the child an adult adoptee born (Check only one) consent to release of my name and address to a birth parent, or if the birth parent is deceased or mentally incompetent, to a full or half sibling, parent of a birth parent, or full or half sibling of a birth parent. deny the release of my name and address to a birth parent, or if the birth parent is deceased or mentally incompetent, to a full or half sibling, parent of a birth parent, or full or half sibling of a birth parent. a relative ( full or half sibling of the adoptee; parent of a birth parent; deceased or mentally incompetent birth parent of full or half sibling of birth parent) of a born (Check only one) consent to release of my name and address to the adopted individual after age 18, or the adoptive parent(s) before the child's 18th birthday. deny the release of my name and address to the adopted individual after age 18, or the adoptive parent(s) before the child's 18th birthday. American LegalNet, Inc. www.FormsWorkflow.com Form 109 (2/07) FILM Agency Involved (if known) Family Court Petition Number (if known) I understand that I may rescind my consent or modify my wishes regarding the release of identifying information by filing a new affidavit with Family Court except to the extent that action has already been taken in reliance thereon. If I do not file an affidavit, I understand that I may be contacted should there be a request for identifying information, and that, if I do not file an affidavit regarding my wishes within 30 working days of that contact, the law permits the release of identifying information. State of Delaware, County of Signature Date Signed and affirmed before me on by Notary Public My Commission expires: This affidavit is NOT a request for information. A separate letter requesting information must be sent to Family Court or the adoption agency. American LegalNet, Inc. www.FormsWorkflow.com