IN THE CIRCUIT COURT OF In the Matter of the Petition of ________________________ For appointment of Confidential Intermediary ) ) ) ) ) ) COUNTY, ILLINOIS No. _______________________ PETITION FOR APPOINTMENT OF A CONFIDENTIAL INTERMEDIARY Comes now __________________________________ petitioning this Court for the appointment of a Confidential Intermediary pursuant to 750 ILCS 50/18.3a and in support of this petition states as follows: 1. I am: (select one) an adopted person 21 years of age or over; or a "surrendered person" 21 years of age or over (Note: A "surrendered person" is a person who was never adopted but whose birth parents' rights were surrendered or terminated); or an adoptive parent of an adopted person under the age of 21; or Please complete the following information, if known: Date of adoption: Adoption case number: ________________________ ________________________ a legal guardian of an adopted or surrendered person under the age of 21; please attach a copy of the order appointing the Petitioner the legal guardian of the adopted or surrendered person; or a birth parent of an adopted or surrendered person 21 years of age or over; or an adult child of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person including your birth certificate as well as a copy of the death certificate for the deceased adopted or surrendered person; or an adult grandchild of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person including your birth certificate, a copy of the death certificate for the deceased adopted or surrendered person and a copy of the death certificate for the child of the deceased or adopted person; or an adoptive parent of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or a legal guardian of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered 1 American LegalNet, Inc. www.FormsWorkFlow.com person as well as a copy of the death certificate for the deceased adopted or surrendered person; or a surviving spouse of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or an adult birth sibling of an adopted or surrendered person and whose adopted or surrendered birth sibling is 21 years of age or over whose common birth parent did not file a denial or option E with the Illinois Adoption Registry Medical Information Exchange indicating that the birth parent does not wish to have contact; Please note that this category of petitioners do not have to register with the Illinois Adoption Registry and Medical Information Exchange before filing a petition; or an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over; please attach copies of the deceased birth parent's death certificate and all documents establishing the relationship between the Petitioner and the deceased birth parent. 2. That ______________________________________________ is an adopted or surrendered person (name of adopted or surrendered person or child's name at birth) having a date of birth of _______________, and on the date of filing this Petition said adopted or surrendered person is _____ years of age. (age) Since the date of my adoption or date that I became a surrendered person, my name has been legally changed by marriage (please attach a copy of a marriage certificate) or by legal change of name (please attach a certified copy of order changing name). Strike if not applicable. 3. ______________________________ was adopted by ______________________________ (name of adopted person) on or about ________________ in_________ County, Illinois, and named ______________. 4. That the Petitioner seeks the appointment of a Confidential Intermediary for the purpose of (select all that apply): exchanging medical or other non-identifying information with one or more mutually consenting biological relatives of the adopted or surrendered person; and/or Exchanging identifying information about one or more mutually consenting biological relatives of the adopted or surrendered person; and/or Obtaining identifying information that would have been found on the adopted person's original birth certificate, if the adopted person was born prior to January 1, 1946 and if the certificate was not found or the petitioner received the non-certified copy of the original birth certificate which omits the name of the birth parent; or Obtaining identifying information that would have been found on the adopted person's original birth certificate, if the adopted person was born after January 1, 1946, and if the certificate was not found. 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. The Petitioner seeks the following biological relative(s) (select all that apply): any/all living birth relative(s)18 years of age or over birth son(s) or daughter(s) 21 years of age or over birth mother birth father birth sibling 18 years of age or over birth sibling who was adopted 21 years of age or over other person 18 years of age or over (please identify): _________________ 6. If the Petitioner is: · an adult child, adoptive parent, legal guardian or surviving spouse of a deceased adopted or surrendered person (strike as applicable); or · an adult birth sibling of an adopted or surrendered person whose adopted or surrendered birth sibling is 21 years of age or over; or · an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over, disclosure of the requested information is of greater benefit than nondisclosure because: Please explain in detail why you are filing the petition. Attach additional pages or documents as needed. _______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________