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): 1. Child's First, Middle, and Last Name at Birth: . Sex: [ ] Female [ ] Male Birthdate: Child's First, Middle, and Last Name after Adoption: . 2. Child's First, Middle, and Last Name at Birth: . Sex: [ ] Female [ ] Male Birthdate: Child's First, Middle, and Last Name after Adoption: . 3. Child's First, Middle, and Last Name at Birth: . Sex: [ ] Female [ ] Male Birthdate: Child's First, Middle, and Last Name after Adoption: . Birth Place: Birth Place: Birth Place: Adoption Agency (if any): . In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Court office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov 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 12/1/14 PAGE 1 OF 2 PAGES Adoption Information Sheet 1F-P-889 American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified STATE OF HAWAI`I FAMILY COURT FIRST CIRCUIT ADOPTIVE PARENTS: CASE NUMBER ADOPTION INFORMATION SHEET FC-A No. Adoptive Father Adoptive Mother Full Legal Name: (include birth/maiden names) Address: Telephone Number: Birth Date: Social Security Number: Ethnic Background: NATURAL PARENTS 0Natural 0Legal 0Adjudicated Name: Father Mother Address: Telephone No.: Birth Date: Social Security Number: Ethnic Background: Legal Only Father (if different from Natural Father) Name: Address: The undersigned declares under penalty of perjury that the above information is true and correct. Date: Reprographics (1/2015) Signature: 0 Attorney 0 Petitioner Pro Se 0 Agency Representative 1F-P-889 FC Adm 12/1/14 PAGE 2 OF 2 PAGES Adoption Information Sheet American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified