OHIO DEPARTMENT OF HEALTH Number BUREAU OF VITAL STATISTICS Date Received ADOPTION DO NOT USE AUTORIZATION FOR RELEASE This form is prescribed for the purpose of authorizing the release of id entifying information pertaining to the biological parent of an adopted person in accordance with Section 3107.41 of the Revis ed Code. Type or Print Legibly 1. Present name of biological parent Last First Middle 2. Date or approximate date of final decree of adoption, if known 3. Name of biological parent at time of final decree of adoption INFORMATION AS REPORTED ON ADOPTED INDIVIDUALS ORIGINAL CERTIFICATE OF BIRTH 4. Childs name at birth 5. Date of birth 6. Place of birth City County State I hereby authorize the Bureau of Vital Statistics, Ohio Department of He alth, to release, in accordance with Section 3107.41 of the Ohio Revised Code, identifying information pertai ning to myself. I realize that the purpose of this release form is to enable the adopted person to obtain identifying inform ation pertaining to their biological parent. 7. Signature of the biological parent Date 8. Mailing address Street Address City State Zip (INSTRUCTIONS ON REVERSE) HEA2774 American LegalNet, Inc. www.USCourtForms.com >>>> 2 ADOPTION AUTHORIZATION FOR RELEASE INSTRUCTIONS Section 3107.41 of the Revised Code provides that an adopted person 21 y ears of age or older may file a petition in a probate court for the release of identifying information pertaining to the adopted persons biological parents or biological sibling. Such identifying information may be provided to the adopted pe rson if a valid authorization for release, completed by the biological parent or biological sibling, is on file wit h the Ohio Department of Health, Bureau of Vital Statistics. A biological parent cannot authorize the release of identifying informat ion for the other biological parent. In order for identifying information to be released for both biological parents , eac h parent must complete and file an authorization for release form. A biological parent cannot authorize the release of ident ifying information pertaining to a biological sibling of the adopted person. The biological sibling must complete and file th e authorization for release form. The biological sibling cannot authorize the release of identifying information on the b iological parents or other biological sibling. A biological parent may request the release of additional information to the adopted person by providing such information on a separate sheet of paper. The additional information shall be signe d, dated, and attached to the authorization for release. Such additional information cannot pertain to the other biolog ical parent unless the other parent has filed an authorization for release of identifying information or to a biological sibling unless the sibling has filed an authorization for release of identifying information. A biological sibling may request the release of additional information t o the adopted person by providing such information on a separate sheet of paper. The additional information sha ll be signed, dated, and attached to the authorization for release. Such additional information cannot pertain t o the biological parents or another biological sibling. ITEM 1. PRESENT NAME OF BIOLOGICAL PARENT The full name of the biological parent at the time of completing form. ITEM 2. DATE OR APPROXIMATE DATE OF FINAL DECREE OF ADOPTION, IF KNOWN If unknown, state unknown. ITEM 3. NAME OF BIOLOGICAL PARENT AT TIME OF FINAL DECREE OF ADOPTION Biological parents surname, as it existed at the time the final decree of adopt ion was granted. If date of final decree is unknown, this item should remain blank. ITEM 4. CHILDS NAME AT BIRTH Adopted childs complete name as reported on original certificate of birth completed at the time of birth. ITEM 5. DATE OF BIRTH The date of the adopted persons birth. ITEM 6. PLACE OF BIRTH The city, county, and state in which the adopted person was born. ITEM 7. SIGNATURE OF BIOLOGICAL PARENT The legal signature of the biological parent that is authorizing the release of identifying data. This item should also be c ompleted with the date signed. ITEM 8. MAILING ADDRESS The complete current mailing address of the biological parent completing the authorization for release. The completed authorization for release form should be mailed to the Bureau of Vital Statistics, Ohio Department of Health, P.O. Box 15098, Columbus, Ohio 43215-0098 American LegalNet, Inc. www.USCourtForms.com