STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ADOPTIONS INFORMATION ACT STATEMENT
Adult Adoptee
(age 21 or older)
This form is used only for adoptions in which the relinquishment for or consent to adoption was signed or the
parent’s rights were involuntarily terminated by court action on or after January 1, 1984
Instructions:
1) Please complete both sides of this form.
2) This form must be witnessed by either a representative of the California Department of Social Services (CDSS), a California (CA)
licensed adoption agency, or notarized by a Notary Public.* If the signing of this form is witnessed by a CDSS or adoption agency
representative, photo identification of the person signing must be obtained and noted on this form. THIS FORM WILL BE
RETURNED TO YOU IF IT IS NOT WITNESSED OR NOTARIZED.
You, as the adult adoptee, may change your decision at any time as to whether or not you wish your name and address disclosed by
sending a notarized letter to that effect, by registered mail, return receipt requested, to the CDSS, CDSS Adoptions District Office, or
licensed adoption agency.
SECTION A
Check boxes that apply:
■ I declare that I am an adult adoptee
(age 21 or older)
and that I was adopted by my adoptive parents listed on the back side of this
form.
■ By signing this form, I voluntarily give my consent to the CDSS or licensed adoption agency to disclose my name and address to
my birth parent(s) upon the request of my birth parent(s).
■ I hereby request, from the CDSS or the licensed adoption agency, my birth parent’s name and most current address shown in
CDSS or agency records. I understand that my birth parent(s) must have consented in writing to the disclosure of his or her name
and address before the information may be released. I understand that the law prohibits CDSS or the licensed adoption agency
from soliciting, directly or indirectly, the execution of such a consent.
■ I hereby request from the CDSS or the CA licensed adoption agency, that my adoptive parents be notified that I have filed this
request before the name and address of my birth parent(s) is released. (Your decision to check or not to check this box does not
affect the information you will receive.)
■ I hereby request nonidentifying background information about my birth parents.
NAME (PLEASE PRINT) OTHER NAME(S) BY WHICH I HAVE BEEN KNOWN
STREET ADDRESS CITY
STATE ZIP CODE
TELEPHONE NUMBER
SIGNATURE DATE
SECTION B
To be completed by a representative of CDSS or CA licensed adoption agency. If Section B or C is
completed, do not complete Section D.
SIGNATURE OF CDSS/ADOPTION AGENCY REPRESENTATIVE
DATE TELEPHONE NUMBER
AGENCY/DEPARTMENT NAME
ADDRESS
IDENTIFICATION OF ADULT ADOPTEE (SPECIFY I.E. DRIVER’S LICENSE, PASSPORT, ETC.)
SECTION C ■
Check if applicable. Notarized signature has been previously submitted to CDSS, or the CA
licensed adoption agency.
SECTION D
To be completed by a Notary Public ONLY IF Section B or C is not completed.
The Notary Public must staple the Acknowledgement document to this form and sign and date below.
SIGNATURE OF NOTARY DATE
*Definition of Notary Public: A Notary Public is a public officer authorized by law to certify documents and to confirm your identity.
Notaries may be located at most banks and credit unions or listed in the yellow pages of your local phone directory.
AD 908A (1/11)
