PROBATE
C OURT
O F
D EFIANCE
C OUNTY,
O HIO
JUDGE
J EFFREY
A .
S TRAUSBAUGH
IN
T HE
M ATTER
O F
_ ____________________________________________________________
( Petitioner)
CASE
N O.
_ _______________
Petition
f or
R elease
o f
A doption
I nformation
The
undersigned
petitions
the
Court
pursuant
to
Section
3107.41
of
the
Ohio
Revised
Code
to
appoint
the
a ppropriate
a gency
t o
d etermine
w hether
t he
P etitioner
i s
a n
a dopted
p erson,
a nd
w hether
o r
n ot
a
Release
of
Information
relating
to
the
Petitioner
has
been
filed
with
the
Department
of
Health
in
Columbus,
O hio,
b y
t he
P etitioner’s
b iological
p arent(s)
a nd/or
s iblings.
Name
o n
B irth
C ertificate
_ ________________________________________________________
Date
o f
B irth
_ _________________
Place
o f
B irth
_ _____________________________
(City,
C ounty
&
S tate)
Adoptive
P arents’
N ames:
Mother
_ __________________________________________________
Father
_ __________________________________________________
Date
o f
A doption
_ ___________________
County
o f
A doption
_ ________________________
(if
k nown)
(if
k nown)
Agency
I nvolved
i n
A doption
_ _____________________________________________________
A
C ERTIFIED
C OPY
O F
T HE
P ETITIONER’S
B IRTH
C ERTIFICATE
I S
A TTACHED
Petitioner
s tates
t hat
t his
C ourt
h as
j urisdiction
t o
h ear
t his
P etition
b ecause
( check
a ppropriate
b ox):
□
Petitioner
i s
a
r esident
o f
_ ____________________
C ounty
O hio,
o r
□
Petitioner
w as
a dopted
i n
t he
P robate
C ourt
o f
_ _______________
C ounty,
O hio
o n
o r
a bout
t he
_____
d ay
o f
_ _________________________,
_ ________
o r
□
Petitioner
i s
n ot
a
r esident
o f
t he
S tate
o f
O hio
a nd
d oes
n ot
k now
t he
n ame
o f
t he
p robate
c ourt
in
O hio
t hat
i ssued
t he
f inal
d ecree
o f
a doption.
A
C OPY
O F
P ETITIONER’S
D RIVER’S
L ICENSE
O R
S TATE
I SSUED
I D
I S
A TTACHED
______________________________
____________________________
Attorney
f or
P etitioner
Petitioner
( signature)
______________________________
____________________________
Typed
o r
P rinted
N ame
Typed
o r
P rinted
N ame
______________________________
____________________________
Address
Address
______________________________
____________________________
Phone
N umber
Phone
N umber
Attorney
R egistration
N o.
_ ________
D.C.
F orm
2 A
–
P etition
f or
R elease
o f
A doption
I nformation