§500.ILLUSTRATION H. Information Exchange Authorization Form

 

Illinois Department of Public Health

STATE OF ILLINOIS ADOPTION REGISTRY

INFORMATION EXCHANGE AUTHORIZATION

 

 

                I, _________________________, state that I am the person who completed the Registration Identification; that I am the age of _____ years; that I hereby authorize the Department of Public Health to give the (circle as applicable) (birth mother) (birth father) (birth sibling) (adopted/surrendered person) (adoptive mother) (adoptive father) (legal guardian(s)) the following:

 

 

(please check the information authorized for exchange)

 

       1.     Only my name and last known address.

 

       2.     A copy of my Illinois Adoption Registry application as specified in the application.

 

       3.     A copy of the original birth certificate of the adopted person.

 

       4.     A copy of the completed medical questionnaire.

 

I am fully aware that I can only be supplied with any information about each circled person if that person has duly executed an Information Exchange Authorization for the information which authorization has not been revoked; that I can be contacted by writing to

 

(insert your own name, complete mailing address and telephone number

or this same information for another person to contact)

NAME		TELEPHONE NUMBER (        )
STREET ADDRESS
CITY	STATE		ZIP CODE

 

Dated					,
(insert date)
	WITNESS			SIGNATURE

 

If adoption agency representative, please state title

STATE OF

Name of agency

City

COUNTY OF

State

Zip Code

 

I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that _______________ personally known to me to be the same person whose name is subscribed to the foregoing Information Exchange Authorization, appeared before me in person and acknowledged that he/she signed such authorization as his/her free and voluntary act and that the statements in such authorization are true.

 

 

Given under my hand and notarial seal on			,
		(insert date)

 

 

SIGNATURE OF NOTARY

 

Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL  62702-5097
VR 161.7 (rev. 05/2000)	Printed by Authority of the State of Illinois  P.O.#   30M   02/00

 

(Source:  Amended at 24 Ill. Reg. 11882, effective July 26, 2000)