Affidavit Of Adopted Person Form - County Of Cuyahoga, Ohio
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1AFFIDAVIT OF ADOPTED PERSON
State of Ohio
County of Cuyahoga
I, ____________________________________________________, being first duly sworn,
(Adopted Person’s Present Name)
say that my adoptive name is ______________________________________________, born
(Adoptive Name)
on _______________________, in ____________________________ hereby request the
(Date of Birth)
(Place of Birth)
Department of Health to provide me with a copy of my original Certificate of birth and copies of
other papers that may be included in my adoption envelope. I am enclosing at two items of
identification. I am aware that other items of identification may be required before the copies
can be mailed.
__________________________________
__________________________________
(Signature of Adopted Person)
(Street Address)
__________________________________
(City, State, Zip Code)
Sworn to before me and subscribed in my presence this ____ day of _______________, 20____ .
__________________________________
__________________________________
(Signature of Notary)
(Date Commission Expires)
(Official Title)
Section 3705.12 of the Ohio Revised Code provides that an adopted person whose birth occurred
in this state and whose adoption was decreed prior to Jan. 1, 1964, may request in writing
(notarized affidavit form) and two items of identification attached to the request, may receive a
copy of the original birth certificate and copies of any papers that may be included in the
adoption envelope. Items of identification include, but are not limited to, a motor vehicle
operator’s license or chauffeur’s license, identification card, marriage record (to provide linkage
between the maiden name and married name), Social Security card, credit card, Military
Identification card, or Employee’s Identification card.
Effective October 1, 1991, the processing fee (this includes searching our state statewide files,
the inspection of the adoption envelope, copying the contents of the adoption envelope, and
mailing the copies to the adopted person is $20.00 Please make your check or money order
payable to Treasury, State of Ohio, Bureau of Vital Statistics, 246 North High Street - P.O. Box
15098, Columbus, Ohio 43215-0098
HEA 3011
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