EFFECTIVE: JANUARY 1, 2005 FILING FEE FOR PETITION TO BREAK SEAL OF ADOPTION: $80.00 MONEY ORDER (VIA MAIL) $80.00 CASH OR MONEY ORDER (IN PERSON) PLEASE BRING OR MAIL COMPLETED PETITION & ADDITIONAL COPY WITH PAYMENT TO: DC SUPERIOR COURT FAMILY COURT CENTRAL INTAKE CENTER 500 INDIANA AVE NW JOHN MARSHALL LEVEL ROOM 520 WASHINGTON, DC 20001 FOR FURTHER INFORMATION PLEASE CALL 202 879-1411 OR 202 879-4335 **IF YOU ARE THE ADOPTEE OR THE ADOPTIVE PARENT REQUESTING COPIES OF THE FINAL DECREE OF ADOPTION ISSUED LESS THAN SIX (6) YEARS AGO, PLEASE USE THE REQUEST FOR A COPY OF THE FINAL DECREE FORM. 1 American LegalNet, Inc. www.FormsWorkflow.com SUPERIOR COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT ADOPTIONS THIS FORM MUST BE NOTARIZED EX PARTE IN THE MATTER OF THE PETITION OF ____________________________ BREAK SEAL CASE NO. _____ BKS______ (case number to be completed by court staff) PRINT YOUR NAME __________________________________________ STREET ADDRESS __________________________________________ CITY, STATE, AND ZIP CODE ___________________________________________ TELEPHONE NUMBER TO BREAK THE SEAL OF ADOPTION. PETITION TO BREAK THE SEAL OF ADOPTION I, _____________________________, am the Petitioner in this case and state that: PRINT YOUR NAME 1. To the best of my knowledge, the adoption agency is _________________________________________ PRINT THE NAME OF THE ADOPTION AGENCY _________________________________________ STREET ADDRESS OF THE ADOPTION AGENCY (if known) _________________________________________ CITY, STATE AND ZIP CODE ( ) __________________________________ PHONE NUMBER OF THE ADOPTION AGENCY (if known) 2 American LegalNet, Inc. www.FormsWorkflow.com 2. The name of the adoptee (if known) is ___________________________________________________________ ADOPTED NAME OF ADOPTEE ________________________________________ BIRTH NAME OF ADOPTEE 3. The approximate date of the adoption (if known) was ________________________________________ (MM/DD/YYYY) 4. The date of birth of the adoptee is ________________________________________ (MM/DD/YYYY) 5. The place of birth of the adoptee is (complete as much information as possible) ________________________________________ NAME OF HOSPITAL ________________________________________ CITY AND STATE OF BIRTH ________________________________________ DOCTOR’S NAME 6. The adoption case number (if known) is ________________________________________ 7. The names of the ADOPTIVE parents and their dates of birth (if known) are ________________________________________ NAME OF ADOPTIVE PARENT ONE ________________________________________ ADOPTIVE PARENT ONE DATE OF BIRTH (MM/DD/YYYY) ________________________________________ NAME OF ADOPTIVE PARENT TWO ________________________________________ ADOPTIVE PARENT TWO DATE OF BIRTH (MM/DD/YYYY) 3 American LegalNet, Inc. www.FormsWorkflow.com 8. The names of the BIRTH parents and their dates of birth (if known) are ________________________________________ NAME OF BIRTH MOTHER ________________________________________ BIRTH MOTHER’S DATE OF BIRTH (MM/DD/YYYY) ________________________________________ NAME OF BIRTH FATHER ________________________________________ BIRTH FATHER’S DATE OF BIRTH (MM/DD/YYYY) 9. I am the Petitioner and I state that (check ONE box that best describes YOUR status and then indicate what you are seeking) I am the adoptee I am the adoptive parent ______ I am only seeking a copy of the Final Decree of Adoption (If the Final Decree of Adoption was entered less than six years ago, please fill out the Final Decree Request Form, for which there is no filing fee, instead of a Petition to Break Seal of Adoption.) OR I am seeking the following information from this petition (check all that apply): ______ Medical information ______ To establish contact with the birth parents ______ Other (please describe, if needed continue in the space at #10) ___________________________________________________________________________ I am the birth parent seeking the following information (check all that apply): ______ To establish contact with the adoptee ______ Other (please describe, if needed continue in the space at #10) ___________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com Other, please state: 1) WHO you are, and your relationship to the adoption; 2)WHY you are completing the Petition; and 3) WHAT information you are seeking: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 10. If there is any additional information you would like to provide, please do so here. Attach an additional page, if needed. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ I, __________________________, solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the Petition to Break the Seal of Adoption and that the factual statements made in it are true to the best of my knowledge, information, and belief. ____________________________ __________________________________________ DATE (MM/DD/YYY) SIGN YOUR NAME ____________________________ PRINT YOUR NAME 5 American LegalNet, Inc. www.FormsWorkflow.com _____________________________, being first sworn under oath, and having provided photographic identification, states that the statements made in the Petition to Break the Seal of Adoption are true to the best of his/her knowledge and belief. ______________ Date __________________________________ Deputy Clerk/Notary Public Subscribed and sworn to before me on ______________________________. _________________________________ Deputy Clerk/Notary Public 6 American LegalNet, Inc. www.FormsWorkflow.com