§500.ILLUSTRATION I. Denial of Information Exchange Form

 

 

 

I, _________________, state that I am the person who completed the Registration Identification; that I am the age of _____ years; that I hereby instruct the Department of Public Health not to give any information about me to the (circle as applicable) (birth mother) (birth father) (birth sibling) (adopted/surrendered person) (adoptive mother) (adoptive father) (legal guardian(s)); that I do not wish to be contacted.

 

(Insert your own name, complete mailing address and telephone number or this same information for another person to contact.  This information is for administrative purposes only and will be used to provide written confirmation that this denial has been filed.)

 

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 Denial of Information Exchange, 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 161.8 (rev.04/2000)                                                                                                               Printed by Authority of the State of Illinois  PO#   30M   02/00

 

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