PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF _________________________________________________________ (Name after adoption) CASE NO. ________________________ AFFIDAVIT OF ADOPTED PERSON I, _________________________________________, being first duly sworn, say that my name after the adoption (Adopted Person's Present Name) proceeding was ______________________________________ and that I was born on ____________________ (Adoptive Name) (Date of Birth) in ___________________________________. (Place of Birth: City and State) I hereby request that the Department of Health provide the Montgomery County Probate Court with a copy of my original certificate of birth and copies of all other papers that may be included in my adoption file. I have presented two items of identificationš to the clerk at the time of filing the Petition. I am aware that I must present two items of identificationš to the clerk prior to information being released to me. ___________________________________________ (Signature of Adopted Person) _________________________________________ (Street Address) ___________________________________________________ (City, State, Zip Code) Sworn to before me and subscribed in my presence, this ________ day of _______________________, 20____. ____________________________ (Signature of Notary) _________________________ (Date Commission Expires) _________________________ (Official Title) šAs per R.C. 3107.38(A)(2), items of identification include a motor vehicle driver's or commercial driver's license, an identification card issued under R.C. 4507.50 to 4507.52, a marriage application, a Social Security card, a credit card, and one item of identification must contain a picture. M.C. FORM 19.5 ­ AFFIDAVIT OF ADOPTED PERSON American LegalNet, Inc. www.FormsWorkFlow.com