§500.ILLUSTRATION K. Surrendered Person Registration Identification Form

 

Illinois Department of Public Health

SURRENDERED PERSON REGISTRATION IDENTIFICATION

(Enter all known information.)

 

I,

state the following:

(present name)

(first)

(middle)

(last)

Surrendered person's

birth name (if known)

(first)

(middle)

(last)

Date of birth

Sex

Race

City and state of birth

Name of birth mother

Race

(if known)

(first)

(middle)

(maiden)

(last)

Name of birth father

Race

(if known)

(first)

(middle)

(last)

I was surrendered for adoption to

(name of agency)

City and state of agency

Date

(approximate)

Other identifying information

 

Name of guardian father							Race
(if applicable	(first)		(middle)		(last)
Maiden name of guardian mother							Race
(if applicable)	(first)	(middle)		(maiden)		(last)

 

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

Name(s) of common birth parent(s)

Race

(first)

(middle)

(maiden)

(last)

Race

(first)

(middle)

(last)

(Please note that (i) you must be at least 21 to register and (ii) if you were not born  in Illinois, then you must submit a certified copy of your birth certificate.)

 

		(signature of surrendered person)
(date)		(printed or typed name of surrendered person)

 

Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL   62702-5097

VR 161.3 (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)