CASE NUMBERSTATE OF HAWAI221I FAMILY COURT CIRCUIT Request Regarding ConfidentialAdoption Records of theFamily Court (Act 80 of 2016) FC-A No.(Type or print in black ink) 1.003 PRESENT NAME OF APPLICANT: (First, middle, and last names)2.003 APPLICANT222S RELATIONSHIP TO ADOPTEE (adopted child): (check 1 box)[] adoptee [] natural parent [] adoptive parent3.003 FULL NAME OF ADOPTEE (First, middle, and last name) (state adoptee222s name at birth orafter adoption, whichever is known):4.003 ADOPTEE222S BIRTHDATE: BIRTH PLACE: Mm/dd/yyyy003 (City, State) 5.003 NAME OF ADOPTIVE FATHER (if known):6.003 NAME OF ADOPTIVE MOTHER (if known):7.003 NAME OF NATURAL FATHER (if known):8.003 NAME OF NATURAL MOTHER (if known):9.003 REQUEST IS FOR:[] Inspection of records[] Medical [] Ethnic Background information[] Copy of Adoption Decree[] Letter to CSEA confirming adoption [] Other: 10.003 REASON FOR REQUEST:11.003 APPLICANT222S MAILING ADDRESS:12.003 APPLICANT222S TELEPHONE NUMBERS: (include area codes)(Home) (Cell) (Court Use Only) Request Regarding Confidential Adoption 07/29/16 Records of the Family Court (Act 80 of 2016) American LegalNet, Inc. www.FormsWorkFlow.com STATE OF HAWAI221I FAMILY COURT CIRCUIT Request Regarding ConfidentialAdoption Records of theFamily Court (Act 80 of 2016) CASE NUMBER FC-A No. 13.APPLICANT DECLARES UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF HIS/HER KNOWLEDGE,INFORMATION, AND BELIEF.14. Date Applicant222s Signature Print Applicant222s complete name: Document Title: Request Regarding Confidential Adoption Records of the Family Court (Act 80 of 2016)Document Date: No. of Pages: 2 was subscribed and sworn to me on in the Circuit, State of Hawai221i by: , who(Print name of person who signed Request) personally appeared before me and to me known to be the person described in and who executed the foregoing document and acknowledge that s/he executed the same as his/her free act and deed. (Signature of Notary Public) (Print Name of Notary Public) Date: My commission expires: Affix Seal FOR FAMILY COURT USE ONLY: (if Request is signed in front of court staff) ----------------------------------------------------------------------------------------------------------------------------------[]Picture ID verified Clerk222s initials: REQUEST IS: [][]APPROVED DENIED Judge, Family Court of the Circuit Print Name of Judge: In accordance with the Americans with Disabilities Act, as amended and other applicable state and federal laws, ifyou require accommodation for a disability, please contact the ADA Coordinator at PHONE NO. , FAX , or TTY at least ten (10) days prior to your hearingor appointment date. Request Regarding Confidential Adoption Records of the Family Court (Act 80 of 2016) Page 2 of 2 07/29/16 American LegalNet, Inc. www.FormsWorkFlow.com