STATE OF HAWAI‘I FAMILY COURT FIRST CIRCUIT CASE NUMBER ADOPTION INFORMATION SHEET FC-A No. Instructions: The Attorney, Petitioner(s) Pro Se, or the Agency completes this form. In “closed” or confidential adoptions this page should not be revealed to the Petitioners when completed. After the adoption has been completed, a copy of this form will be submitted to the Adoptions Records Unit for its use upon receipt of disclosure requests. (See Section 578-15 of the Hawai‘i Revised Statutes.) Child(ren)’s last name at birth: Child(ren)’s First and Middle Names Sex BirthDate Birth Place Child(ren)’s Full Name After Adoption 1. 2. 3. 4. Adoption Agency (if any): ADOPTIVE PARENTS: Adoptive Father Adoptive Mother Father Mother Full Legal Name (include birth/maiden names) Address E-Mail Address Telephone Number Birth Date Social Security Number Ethnic Background NATURAL PARENTS: [ ] Natural [ ] Legal [ ] Adjudicated Name Address Telephone No. Birth Date Social Security Number Ethnic Background Legal Only Father (Full Name and Address) The undersigned declares under penalty of perjury that the above information is true and correct. Date: Signature: [ ] Attorney [ ] Petitioner Pro Se [ ] Agency Representative In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Office of the Chief Administrator at PHONE NO. 954-8200, FAX 954-8308, or TTY 539-4853 at least ten (10) working days prior to your hearing or appointment date. Please call Family Court Service Center at 954-8290, if you have any questions about how to fill out this form. FC Adm 5/8/12A Reprographics (05/12) 1F Adoption Information Sheet 1F-P-889 American LegalNet, Inc. www.FormsWorkFlow.com