Fillable DHS-1919, Parent's Consent/Denial To Release Information To Adult Adoptee (Michigan)

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DHS-1919, Parent's Consent/Denial To Release Information To Adult Adoptee (Michigan)

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DHS-1919 (Rev. 3-16) Previous edition obsolete.
PARENT’S CONSENT/DENIAL
TO RELEASE INFORMATION TO ADULT ADOPTEE
Michigan Department of Health and Human Services
Central Adoption Registry
A new statement may be sent to the Central
Adoption Registry any time to withdraw a previous
consent or to withdraw a previous denial. Release
of identifying information will be based on the most
recent statement on file in the Central Adoption
Registry.
A parent giving consent should send to the Central
Adoption Registry a new statement if either his/her
name or address changes.
A separate form must be filled out for each child for whom
you are giving consent/denial.
Send this original form and a copy of an approved photo
identification to the Central Adoption Registry address below:
MICHIGAN DEPARTMENT OF HEALTH
AND HUMAN SERVICES
CENTRAL ADOPTION REGISTRY
PO BOX 30037
LANSING MI 48909
I state that I am the father mother of the child described below.
I hereby give consent do not give consent* to the release of my name
and address to this child when he/she is 18 years of age or older.
(*If the denial box is checked, the parent may provide an explanation as to why he/she does not wish to
release name and address).
Reason:
FOR OFFICE USE ONLY
Birth Date
A copy of an approved photo identification is included with this form. (Example: Current
driver’s license, current state issued photo identification or current student photo ID)
CHILD INFORMATION:
Child’s Birth Date (Mo., Day, Yr.)
Child’s City of Birth
Child’s County of Birth
Child’s State of Birth
Adoptee’s Birth Name (Last, First, Middle)
Child’s Birth Mother’s Name When Parental Rights were Released or Terminated
PARENT INFORMATION:
My Birth Date (Mo., Day, Yr.)
Apartment or Lot Number
City
State
Zip Code
Telephone Number
Email
Date
The Michigan Department of Health and Human Services
(MDHHS) does not discriminate against any individual or group
because of race, religion, age, national origin, color, height,
weight, marital status, genetic information, sex, sexual orientation,
gender identity or expression, political beliefs or disability.
AUTHORITY: MCLA 710.68.
COMPLETION: Voluntary.
PENALTY: None
DISTRIBUTION: ORIGINAL - Michigan Department of Health and Human Services
Central Adoption Registry
PO Box 30037
Lansing, Michigan 48909
COPY - Keep for your records.
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DHS-1919, Parent's ConsentDenial To Release Information To Adult Adoptee (Michigan)

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Completed 1 December 2021

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