Fillable Form Doh-4455 - Adoption Information Registry Birth Parent Registration Form printable pdf download

Form Doh-4455 - Adoption Information Registry Birth Parent Registration Form

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Adoption Information Registry Birth Parent Registration Form

NEW YORK STATE DEPARTMENT OF HEALTH

Vital Records Section

This form is to be completed by birth parents who consent to the adoption or who execute an

FOR OFFICIAL NYS USE ONLY

instrument of surrender. It is used to register a birth parent’s agreement or non-agreement to

Registry #

the release of the birth parent's name and address by the Adoption Registry to the adoptee (the

adopted child). This identifying information will be given to the adopted child only when the

Date

child reaches at least eighteen years of age and voluntarily registers with the Adoption Registry.

This form may also be used at any time after the adoption to agree to the release of identifying

information, to withdraw your agreement or to update your contact information.

Print Form

Instructions for the birth parents, adoption agencies, attorneys, courts and the NYC Department

of Health and Mental Hygiene are on page 2.

1. Birth Parent Information:

Check one:

Birth Mother

Birth Father

Date of your birth:

MM/DD/YYYY

Name of birth parent

First Name:

Middle Name:

Current Last Name:

Maiden Last Name:

(If Applicable)

Contact Information:

Mailing address

Street:

City/Town:

State:

ZIP:

Email address:

Phone: (

)

2. Adoptee Information:

Name given to child at birth

First Name:

Middle Name:

Last Name:

Date of Birth:

Town, city or village

MM / DD / YYYY

of birth of adoptee:

, New York State.

3. Agency Information:

Name of Adoption Agency or Attorney if private adoption:

Name of Court:

4. Birth Parent Statement:

I have read the Notice to Birth Parents on the reverse side of this form and I understand that if I agree to the release of identifying information the

adoptee can be given my name and known address and that I will not be notified when the information is released. Further, I swear or affirm under

penalty of perjury that all of the information provided on this application is true and accurate to the best of my knowledge and belief.

Yes

, I agree that my name and address can be given to the

STATE OF

adopted child if he or she registers with the Adoption Information

SS:

Registry on or after his or her eighteenth birthday.

COUNTY OF

, I do not wish my name and address to be given to the

adopted child.

If you change your mind after submitting this form, please complete a