Fillable Application For Adoption Registry Services printable pdf download

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APPLICATION FOR ADOPTION REGISTRY SERVICES

INSTRUCTIONS: Complete this form to register identifying information with the Florida Adoption Reunion Registry. A copy of your

driver’s license or birth certificate must be attached. Information will be released to parties you have listed in Section D if both parties

have registered. Print or type all information, leaving blank questions you cannot answer. Sign and date Section F.

REMITTANCE: A non-refundable fee of $35.00 (check or money order) should accompany your completed application. If such fee will

create a financial hardship, a letter justifying waiver of the fee should accompany the application. NOTE: In addition to other penalties

imposed by law, a $10.00 service fee will be charged for dishonored checks or drafts.

MAIL WITH FEE TO: Adoption Registry, 1317 Winewood Boulevard, Tallahassee, FL 32399-0700

SECTION A: APPLICANT’S IDENTITY

APPLICANT ’S PRESENT NAME (FIRST , MIDDLE, LAST )

CURRENT ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)

OT HER NAMES KNOW N AS:

SOCIAL SECURIT Y NUMBER

RELAT IONSHIP T O ADOPT EE

DAT E AND PLACE OF BIRT H (CIT Y, COUNT Y, ST AT E)

TELEPHONE NUMBER(S)

(Home)

(Work)

ext.

SECTION B: STATUS OF ADOPTEE AT BIRTH (Furnish all known information)

CHILD’S NAME AT BIRTH (FIRST, MIDDLE, LAST)

NUMBER IN UPPER RIGHT-HAND CORNER OF CHILD’S ORIGINAL BIRTH CERT IFICAT E

CHILD’S DAT E OF BIRT H

SEX

MAIDEN NAME OR NAME USED BY NATURAL MOTHER AT BIRTH OF CHILD (FIRST, MIDDLE, LAST)

PLACE OF BIRT H (CIT Y, COUNT Y, ST AT E)

NAME OF NATURAL FATHER (FIRST, MIDDLE, LAST)

SECTION C: STATUS OF ADOPTEE AFTER ADOPTION (Furnish all known information)

CHILD’S NAME AFTER ADOPTION (FIRST, MIDDLE, LAST)

NAME OF ADOPTIVE FATHER AS NAMED ON DECREE (FIRST, MIDDLE, LAST)

NUMBER IN UPPER RIGHT-HAND CORNER OF CHILD’S BIRTH CERTIFICATE

NAME OF ADOPTIVE MOTHER AS NAMED ON DECREE (FIRST, MIDDLE, LAST)

SECTION D: CONSENT TO RELEASE IDENTIFYING INFORMATION

BY MY SIGNATURE BELOW, I hereby consent to disclosure by the Florida Adoption Reunion Registry of the information which I have

provided in Section A of this application, to the following person(s), upon verification of identity and relationship, listed by their

relationship to the adoptee (for example: ADOPTEE, BIRTH PARENTS, etc.):

LIST PERSONS YOU WANT

INFORMATION GIVEN TO:

I would like to receive identifying information for any individual listed above.

YES

SECTION E: AGENT’S IDENTITY

Complete only if agent is used and enclose a witnessed statement of authority from principal.

AGENT ’S NAME

CURRENT ADDRESS (NUMBER, STREET, CITY, STATE, ZIP CODE)

T ELEPHONE NUMBER

ext.

SECTION F: RESPONSIBILITY OF APPLICANT

PRIVACY ACT STATEMENT

You are not required to provide us social security number(s), however, if you give us your social security number(s) we can determine

your eligibility for assistance or services faster and more accurately. Social security numbers are used by the Department for identity

verification related to administration of our programs.

I understand the importance of providing complete information and attest that the information provided above is accurate to the best of

my knowledge. I understand in accordance with Section 837.06, Florida Statutes, that making false statements in writing with the intent

to mislead a public servant in the performance of his official duty is a misdemeanor of the second degree.

I also understand identifying information filed with the Adoption Registry will be disclosed in accordance with the consent of those duly

registered, upon verification of their identity. I acknowledge responsibility for notifying the Registry to expand, restrict, withdraw, or

update this information, including changes of name, address, and telephone number by submitting form CF 1491 and fee.

Signature of applicant __________________________________________________________ Date signed ___________________

CF 1490, PDF 08/2011

[65C-16.017, F.A.C.]

Application For Adoption Registry Services

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