Fillable Appendix K COURT AND AGENCY REQUEST FOR ADOPTION (County of York)

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Appendix K COURT AND AGENCY REQUEST FOR ADOPTION (County of York)

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Appendix K
Request for Adoption Information or Contact with Specified Persons 03/11
Page 1 of 2
COURT AND AGENCY REQUEST
FOR ADOPTION INFORMATION (NON-IDENTIFYING OR IDENTIFYING) OR CONTACT WITH
SPECIFIED PERSONS
This form is provided as a sample that may be adapted for use by the courts and the agencies.
You may request information about your own adoption or the adoption of a family member as listed below. If the court or
agency has any information on file, we will provide what is allowable by law to you within 120 days. Any information
released will be mailed to the requestor. If no information is on file at the time of the request, a notice of that fact will be
mailed. Requests remain active and if information is received in the future, information will then be mailed to the requestor.
It is important to notify us of any change in your contact information. When you have completed the form, please
forward it to: (insert the information for the court that finalized the adoption, the agency that coordinated the adoption or the
successor agency) Please type or print in black or blue ink. If you don’t know or are unsure about an answer, leave it blank.
I (the requestor) am one of the following:
Adoptee who is at least 18
Adoptive parent of an adoptee who is under 18, or adjudicated incapacitated or deceased
Legal guardian of an adoptee who is under 18, or adjudicated incapacitated
Descendent of a deceased adoptee
Birth parent of an adoptee who is at least 21
Birth grandparent of an adoptee who is at least 21 (Birth parent must consent to the release of the information or be
adjudicated incapacitated or deceased)
Birth sibling if both adoptee and sibling are at least 21 and (check one):
Sibling remained in the custody of the birth parent who has given consent for release of this information or who is
incapacitated or deceased
Sibling was adopted out of the same birth family as the adoptee for whom I am requesting information
Sibling was not adopted out of the same birth family and did not remain in the custody of the birth parent
I am requesting information about or contact with the following individuals:
An adoptee 21 or older;
A birth parent of adoptee;
A parent of the birth parent of an adoptee who is 21 or older if the birth parent consents, is incapacitated or is
deceased;
A birth sibling of an adoptee if both the sibling and adoptee are 21 or older and the following criteria exist:
The birth sibling remained in custody of the birth parent and the birth parent consents to the release of the
information or contact, is deceased or incapacitated;
The birth sibling and the adoptee were both adopted out of the same birth family; or
The birth sibling was not adopted out of the birth family and did not remain in the custody of the birth parent.
REQUESTOR’S CONTACT INFORMATION
NAME (Last, First, Middle) DATE OF BIRTH (MM/DD/YYYY)
MAILING ADDRESS
CITY STATE ZIP TELEPHONE
( )
I am requesting Identifying Information Non-Identifying Information Both
Identifying Information will include names and contact information.
Non-identifying Information does not include names and contact information but could include medical, social and educational
information, etc.
You may specify that you do or do not wish contact with the person whose information you are requesting.
I do wish to have contact with the individual specified.
I do not wish to have contact with the individual specified.
Appendix K
Request for Adoption Information or Contact with Specified Persons 03/11
Page 2 of 2
REQUEST FOR ADOPTION INFORMATION ABOUT OR CONTACT WITH SPECIFIED PERSONS
Please provide as much information as you know about this person.
CURRENT NAME (Last, First, Middle)
NAME RECORDED ON THE ORIGINAL BIRTH CERTIFICATE
(Last, First, Middle)
DATE OF BIRTH
(MM/DD/YYYY)
GENDER
MALE FEMALE
PLACE
OF BIRTH
COUNTY CITY/MUNICIPALITY STATE HOSPITAL (if known)
ADOPTIVE PARENT INFORMATION
ADOPTIVE MOTHER’S NAME (Last, First, Middle, Maiden) ADOPTIVE FATHER’S NAME (Last, First, Middle)
MAILING ADDRESS MAILING ADDRESS
CITY STATE ZIP CITY STATE ZIP
BIRTH PARENT INFORMATION
BIRTH MOTHER’S NAME (Last, First, Middle, Maiden) BIRTH FATHER’S NAME (Last, First, Middle)
MAILING ADDRESS MAILING ADDRESS
CITY STATE ZIP CITY STATE ZIP
ADDITIONAL INFORMATION
LEGAL GUARDIAN’S NAME (Last, First, Middle, Maiden) COUNTY COURT OR AGENCY THAT FACILITATED OR
ARRANGED THE ADOPTION
MAILING ADDRESS MAILING ADDRESS
CITY STATE ZIP CITY STATE ZIP
BIRTH CERTIFICATE STATE FILE NUMBER DATE OF ADOPTION FINALIZATION
PLACE OF ADOPTION
FINALIZATION
COUNTY CITY STATE
I certify that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct
under penalty of law (section 4904 of the Pennsylvania Crimes Code). Further, I understand that it is my responsibility to notify the
registry of any change in address.
SIGNATURE DATE
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Appendix K COURT AND AGENCY REQUEST FOR ADOPTION (County of York)

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Completed 6 August 2020

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