Fillable RELEASE OF INFORMATION AUTHORIZATION ADULT ADOPTEE State of (Third Judicial Circuit of Michigan)

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RELEASE OF INFORMATION AUTHORIZATION ADULT ADOPTEE State of (Third Judicial Circuit of Michigan)

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DHS-1920 (Rev. 8-05) Previous edition may be used. MS Word 1
RELEASE OF INFORMATION AUTHORIZATION ADULT ADOPTEE
State of Michigan – Department of Human Services
I hereby authorize the adoption agency and/or the probate court named below, in accordance
with P.A. 288 of 1939, Chapter 10, to release, upon request, my name and address to:
My Biological Parent(s) An Adult Brother/Sister
CURRENT INFORMATION
Current Name (Last, First Middle Birth Date
Month
Day
Year
Current Address (Street Number and Name) Apartment Number
City State Zip Code Telephone Number
A/C ( )
ADOPTION INFORMATION
Adoptive Name (Last, First, Middle) Name Before Adoption (If Known)
Adoptive Mother’s Name Adoptive Father’s Name
Birth Mother’s Name Birth Father’s Name
Name of Probate Court Name of Placing Agency
Additional Comments
Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex,
religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known
to a DHS office in your area.
AUTHORITY: MCLA 710.68.
COMPLETION: Voluntary.
PENALTY: None.
DISTRIBUTION: 1st Copy – Probate Court that Finalized Adoption
2nd Copy – Adoption Agency
3rd Copy – Keep for Your Records
Adult Adoptee’s Signature Date
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RELEASE OF INFORMATION AUTHORIZATION ADULT ADOPTEE State of (Third Judicial Circuit of Michigan)

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Completed 29 July 2020

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