DHS-1925 (Rev. 8-05) Previous edition may be used. MS Word
REQUEST BY ADULT ADOPTEE FOR IDENTIFYING INFORMATION
State of Michigan
Department of Human Services
I hereby request, from my adoption records, my name before placement in adoption, the names of
my biological parents, including their current names, if available, most recent address or addresses
of biological parents, and names of biological siblings at the time of termination.
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
Also, please send me non-identifying information from my file.
Additional Comments
Adult Adoptee’s Signature Date
DISTRIBUTION: Original - Adoption Agency or Court that
Finalized the Adoption
Copy - Keep for Your Records
AUTHORITY: MCLA 710.68.
COMPLETION: Voluntary.
PENALTY: None.
De
artment of Human Services
DHS
will not discriminate a
ainst an
individual or
rou
because of race, sex, reli
ion, a
e, national ori
in, color,
hei
ht, wei
ht, marital status,
olitical beliefs or disabilit
. If
ou need hel
with readin
, writin
, hearin
, etc., under the Americans with Disabilities Act,
you are invited to make your needs known to a DHS office in your area.
