ADULT FORMER SIBLING STATEMENT TO RELEASE INFORMATION TO ADULT ADOPTEE Michigan Department of Human Services CENTRAL ADOPTION REGISTRY • • • I state that I am the Keep the yellow copy for your records. • A sibling giving consent should send to the Central Adoption Registry a new statement if either his/her name or address changes. A separate form must be filled out for each sibling for whom you are giving consent/denial. • A new statement may be sent to the Central Adoption Registry any time to withdraw a previous consent or to withdraw a previous denial. Release of identifying information will be based on the most recent statement on file in the Central Adoption Registry. Send the White copy to the Central Adoption Registry address below: MICHIGAN DEPARTMENT OF HUMAN SERVICES CENTRAL ADOPTION REGISTRY PO BOX 30037 LANSING MI 48909 brother sister of the child described below. I hereby give consent do not give consent to the release of my name and address to this child when he/she is 18 years of age or older. Birth Date (Month/Day/Year) CHILD INFORMATION: Child’s Full Name at Birth (Last, First, Middle) Child’s Birth Date (Month/Day/Year) Child’s City of Birth Child’s County of Birth Child’s State of Birth COMMON BIRTH PARENT INFORMATION (If known): Current Name of Birth Mother (Last, First, Middle) Birth Date (Month/Day/Year) Mother’s Name When Parental Rights Were Released or Terminated (Last, First, Middle) Name of Birth Father (Last, First, Middle) Birth Date (Month/Day/Year) My Current Name (Last, First, Middle) Birth Date (Month/Day/Year) Phone No. ( ) Name at Time Parental Rights Were Released or Terminated, if Different (Last, First, Middle) Current Address (Street Number and Name) Adoptee’s Birth Name (Last, First, Middle) FOR OFFICE USE ONLY SIBLING INFORMATION: City State Brother/Sister Signature Date Signed AUTHORITY: P.A. 288 of 1939, as amended, MCLA-710.27(5) COMPLETION: Voluntary. PENALTY: None Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. DHS-1917 (Rev. 7-05) Previous edition obsolete. MS Word Zip Code 1 DISTRIBUTION: ORIGINAL - Michigan Department of Human Services Central Adoption Registry P.O. Box 30037 Lansing, Michigan 48909 COPY Sibling’s File Copy American LegalNet, Inc. www.FormsWorkflow.com