Application Form - Person Freed For Adoption But Not Subsequently Adopted Or Person Acting On Adopted Person'S Behalf - Vs210c

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Maine Center for Disease Control and Prevention (Maine CDC)
220 Capitol Street
11 State House Station
Augusta, Maine 04333-0011
(207) 287-3771
Fax : (207) 287-1093
TTY Users: Dial 711 (Maine Relay)
Use the Tab Key to go from one field to the next
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Application – Person Freed for Adoption but Not Subsequently Adopted
– VS210C
or Person Acting on Adopted Person’s Behalf
_______________
State File Number
1. Name
2. Birthdate
3. Sex
4. Birthplace
Male
Female
st
5a. Parent’s Name Prior to 1
Marriage
Marriage on Birth Certificate
st
5b. Other Parent’s Name Prior to 1
6a. Date Freed for Adoption
6b. Name and Location of Court
7. Name
8. Mailing Address
9. Status (Check only one)
Person 18 years of age or older who was freed for adoption but not subsequently adopted.
Legal custodian/guardian of person under 18 who was freed for adoption but not subsequently adopted.
Legal custodian/guardian of person determined by a court to be incapacitated and who was freed for adoption but not
subsequently adopted.
10. I wish contact with my biological
parents.
Yes
No
11. I wish contact with my biological full siblings who are 18 years of age or
older.
Yes
No
12. I wish contact with my biological half-siblings who are 18 years of age or
older.
Yes
No
13. If my biological parent or other parent has died, I wish contact with these relatives of that parent.
Parent
Other Parent
Grandparent
Full Sibling
Half Sibling
Aunt
Uncle
Cousin
SPECIAL INSTRUCTIONS:
I hereby certify that I am the person named above, or the legal custodian or guardian of that person, and that I wish contact
with the biological parents and/or other individuals indicated above.
Signed: ________________________________________________________________ Date: _______________________
Check No.___________ Amount Paid ______________
S:\vradminf\AMaster forms\VS-210C.pdf R 04/2014

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