Name of court where you will file your Affidavit:

State where you will file your Affidavit:
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County where you will file your Affidavit:

Your Current Full Name: ("First, Middle Initial, Last")

The Full Name your adoptive parents gave you: ("First, Middle Initial, Last")

Your Street Address (No Post Office Boxes):

2nd street address if needed:

Your City:

Your State:
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 

Your County:

Zip Code:

Telephone Number:

Enter the Court File Number Of Your Adoption If You Know It.

The City Where You Were Born:

State of birth:
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 

County of birth:

State where you will get this Affidavit Notarized (State you are now in is okay for Notarization if you are mailing your document to the proper Court Clerk):
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 

County where this Affidavit will be Notarized:

Your Birth Date:
January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

The Hospital Where You Were Born:

Your Adoptive Father: ("First, Middle Initial, Last")

Your Adoptive Mother's name at time of your adoption: ("First, Middle Initial, Last")

Enter the Full Name of the Adoption Agency or Attorney that handled your adoption if you know it:

Street Address Of Adoption Agency or Attorney:

City Of Adoption Agency or Attorney:

State Of Adoption Agency or Attorney:
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 

Zip Code Of Adoption Agency or Attorney:

Select the paragraph that best fits your situation. Don't worry about filling in the agency information. It will be inserted into your document for you from the information you provided above.

My adoption was handled by the above listed agency or attorney.

I do not know the agency or attorney that handled my adoption.

Select the paragraph that best fits your situation. Your chance of having the Court approve your request to open your adoption record is greater when medical reasons are indicated. If you are selecting medical reasons, a written statement from a board certified medical doctor indicating that it is critical that medical, psychological or genetic information be conveyed, and states clearly the reasons why this is necessary MUST accompany your Affidavit. Go to this link "Blog on Rejection and Failure" for an adoptees personal research and input on the mental and physical affects of being adopted if you are unsure of how to put your feelings into words.

I am contemplating a future with children and believe that I have a responsibility to know about my natural family's medical and genealogical background for my family.

I have children and believe that I have a responsibility to know about my natural family's medical and genealogical background for my family.

I have a medical need for health information of genetic significance that may affect my physical or mental health. A letter from my physician is attached.

Select one.

I desire to be informed that registry records indicate that I have a biological sibling who has registered under this subchapter.

I do not desire to be informed that registry records indicate that I have a biological sibling who has registered under this subchapter.

Please type in the names and complete addresses of the Health Department, Vital Records Division, that you will need to notify of your request. Your State Vital Records office locations can be found by clicking on this link: www.vitalrec.com.

When the questionnaire is finished and you hit the Submit button you will be taken to a page where you can verify the information you've put in. Please review your answers before you hit the Submit button. If you find a mistake, hit your back button and correct it before you move forward. When you print your final document out, only print on ONE side of the paper. The court will not accept documents printed on both sides.