PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE IN THE MATTER OF _________________________________________________________ (Petitioner) CASE NO. ________________________ PETITION FOR RELEASE OF ADOPTION INFORMATION The undersigned petitions the Court pursuant to Section 3107.41 of the Revised Code to appoint the appropriate agency to determine whether the Petitioner is an adopted person, and whether or not a Release of Information relating to the Petitioner has been filed with the Department of Health in Columbus, Ohio, by the Petitioner’s biological parent(s) and/or siblings. Name on Birth Certificate _____________________________________________________________ Date of Birth ________________________ Place of Birth ___________________________________ (City, County & State) Adoptive Parents’ Names: Mother ________________________________________________________ Father ________________________________________________________ Date of Adoption ________________________ County of Adoption ___________________________ (If Known) (If Known) Agency Involved in Adoption __________________________________________________________ A CERTIFIED COPY OF THE PETITIONER’S BIRTH CERTIFICATE IS ATTACHED Petitioner states that this Court has jurisdiction to hear this Petition because [check appropriate box]: Petitioner is a resident of __________ County Ohio, or Petitioner was adopted in the Probate Court of ____________County, Ohio on or about the _______ day of _______________________, _______, or Petitioner is not a resident of the State of Ohio and does not know the name of the probate court in Ohio that issued the final decree of adoption. A COPY OF PETITIONER’S DRIVER’S LICENSE OR STATE ISSUED ID IS ATTACHED _____________________________________ ___________________________________ Attorney for Petitioner Petitioner ___________________________________________________ Typed or Printed Name ________________________________________________ Typed or Printed Name ___________________________________________________ Address ________________________________________________ Address ___________________________________________________ ________________________________________________ ___________________________________________________ Phone Number (include area code) _________________________________________________ Phone Number (include area code) Attorney Registration No. ______________________________ M.C. FORM 19.2 – PETITION FOR RELEASE OF ADOPTION INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com