Request for Court Adoption Records Name (person making request) Mailing address Telephone number Child222s birth name Child222s adopted name Child222s date of birth County and Case Number Year of adoption List of specific records requested Please check the boxes that apply to you: If you are mailing in your records request, please sign this form in front of a notary public. Signature: Date: State of County of Signed (or attested) before me on by . NOTARY PUBLIC/COURT CLERK My Commission Expires: Court staff use only: ID checked: Driver222s License Other: Records released: Amount Paid $ Court staff initials: Date: Fee Code for Redaction/Segregation: RSAI 2/5/14 No court order required. Court order required (segregation and redaction may apply) Adoptive parent Petitioner222s (Adoptive parent222s) attorney of record A representative from the Department of Human Services. The adopted person (must be 18 years of age or older ) (home study exempt from disclosure unless court orders otherwise) I /my agency signed a document in the court record, and I am requesting access only to that record. (redaction required) (if biological parent, court order required if child was surrendered to DHS or parental rights were terminated ) The biological parent My parental rights were terminated by court order, or I surrendered and released my child to DHS pursuant to ORS 418.270 Other: American LegalNet, Inc. www.FormsWorkFlow.com