Commonwealth of Massachusetts
Juvenile Court Department
Division
RE:
In the Matter of the Adoption of
AUTHORIZATION FOR CRIMINAL RECORD CHECK
I hereby authorize the Juvenile Court to conduct a criminal record check to determine
whether I have a criminal record. I understand the criminal record check is intended for
use by the court in conjunction with my petition to adopt the above named child. I further
understand that the court will not consider my petition for adoption without conducting a
criminal record check of both petitioners. Therefore, the information below is willingly
supplied by me, and my signature indicates my permission for this record check to be
completed.
Name:
Current Address:
Social Security No.:
Gender: Female Male Date of Birth:
Place of Birth:
Maiden Name (if applicable):
Other Names or Aliases used:
Mother's Name:
Father's Name:
Date:
(Signature)
NOTARIZATION
The above signed made oath before me on ______________________ that this affidavit
is her/his free act and deed.
Notary Public: ________________________
Print Name: __________________________
My Commission Expires: _______________
JV-Authorization for Criminal Record Check (02/25/2009)
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