I,

, state that I am

(present name)

(first)

(middle)

(last)

the

of the following child:

(birth mother or birth father)

Child's original name

(first)

(middle)

(last)

Hour of birth

a.m./p.m.

Date of birth:

(circle one)

City and state of birth

Sex

Name of hospital

Birth father's full name

(first)

(middle)

(last)

Date of birth

Race

City and state of birth

Name of birth mother as

shown on original birth certificate

(first)

(middle)

(last)

Date of birth

Race

City and state of birth

My birth child was surrendered to

(name of agency)

(city and state of agency)

Approximate date child was surrendered

My birth child was placed for adoption on

(date)

City and state

Names of adoptive parents (if known)

Other identifying information

Provide name(s) at birth and ages of siblings(s) having a common birth parent with  surrendered person (if known).

If more than one sibling, please give information requested below on reverse side of this form.

(first)

(middle)

(last)

Date of birth

Sex

Race

(or approximate age)

City and state of birth

(signature of birth parent)

(date)

(printed or typed name of birth parent)