Commonwealth of MassachusettsJuvenile Court Department DivisionRE:In the Matter of the Adoption ofAUTHORIZATION FOR CRIMINAL RECORD CHECKI hereby authorize the Juvenile Court to conduct a criminal record check to determinewhether I have a criminal record. I understand the criminal record check is intended foruse by the court in conjunction with my petition to adopt the above named child. I furtherunderstand that the court will not consider my petition for adoption without conducting acriminal record check of both petitioners. Therefore, the information below is willinglysupplied by me, and my signature indicates my permission for this record check to becompleted.Name:Current Address:Social Security No.:Gender:Female Male Date of Birth:Place of Birth:Maiden Name (if applicable):Other Names or Aliases used:Mother's Name:Father's Name:Date: (Signature)NOTARIZATIONThe above signed made oath before me on that this affidavitis her/his free act and deed.Notary Public: Print Name: My Commission Expires: JV-Authorization for Criminal Record Check (02/25/2009) American LegalNet, Inc. www.FormsWorkFlow.com