PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the ADOPTION of:______________________________________________________________ (Child's Name After Adoption) Case No: ______________________ Date: _________________________ PETITION FOR RELEASE OF IDENTIFYING INFORMATION The undersigned Petitioner hereby petitions this Court for release of information concerning his/her adoption, if any, pursuant to R.C. 3107.41 and herein submits the following information concerning himself/herself. Date of Birth City, County, and State of Birth Adoptive Name on Birth Certificate Current Name** Names of Adoptive Parents Current Address Home Phone Business Phone Agency Involved in Adoption (if known) **If your current name differs from the name in your adoption file, you must show proof of the name change. Petitioner further says that this Court has jurisdiction to hear this Petition because: (check appropriate box). Petitioner is a resident of Wood County, Ohio Petitioner was adopted in the Probate Court of Wood County, Ohio on or about the ______ day of _____________________, _______. Petitioner is not a resident of the State of Ohio and does not know which Probate Court entered the Final Decree of Adoption in the adoption proceeding. Therefore, the Petitioner hereby requests this Court to appoint an agency and issue an order pursuant to R.C. 3107.41(B)(1) to the Department of Health requiring it to provide the agency with either a copy of the original birth record or, if the department does not possess the original birth record, the identity of the Court involved in the Petitioner's adoption. _________________________________________________ Petitioner's Signature FORM 40.0 - PETITION FOR RELEASE OF INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com