PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE IN THE MATTER OF CASE NO. APPLICATION FOR REGISTRATION OF FOREIGN BIRTH RECORD Registrant prays that the fact of birth be established and that the Ohio Department of Health be ordered to issue a foreign birth record of an adopted person in accordance with R.C. 3107.18 as follows: Full Name of Child (at time of adoption) Social Security No. Exact Place of Birth Date of Birth Male Full Name of Father Full Maiden Name of Mother Age of Father (at time of this birth) Age of Mother (at time of this birth) Birthplace of Father Female Birthplace of Mother Registrant has attached the foreign birth record and foreign adoption decree/certificate of adoption and an English translation of both. The registrant being first duly sworn says that the facts stated in the foregoing application are true as he/she verily believes and prays that the Court order the Ohio Department of Health to issue a foreign birth record. Signature of Registrant Printed or Typed Name of Registrant Address ( ) Phone Number (include area code) Sworn to before me and subscribed in my presence this day of , . (SEAL) Notary Public H.C. FORM 118.50 - APPLICATION FOR REGISTRATION OF FOREIGN BIRTH RECORD 02/10/03 American LegalNet, Inc. www.FormsWorkflow.com