Petition For Release Of Adoption Information Form - Court Of Defiance County, Ohio

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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  

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