Form Il482-1020 - Denial Of Information Exchange - Illinois Department Of Public Health
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1STATE OF ILLINOIS ADOPTION REGISTRY
DENIAL OF INFORMATION EXCHANGE
State of Illinois
Illinois Department of Public Health
I, ______________________________________, state that I am the person who completed the Registration
Identification; that I am ______ years of age; that I hereby instruct the Department of Public Health ot to give any
information about me to the following person(s)
birth mother
birth father
grandparent
o
o
o
(check as applicable)
birth sibling
adopted/surrendered person
adoptive mother
adoptive father
legal guardian of an adopted or
o
o
o
o
o
surrendered person
birth aunt
birth uncle
adult child of a deceased adopted or surrendered person
surviving
o
o
o
o
spouse of a deceased adopted or surrendered person
all eligible relatives; that I do not wish to be contacted.
o
(Insert your own name, complete mailing address and telephone number or this same information
for another person you wish us to contact. This information is for administrative purposes only and will be
used to provide written confirmation that this denial has been filed.)
NAME
TELEPHONE NUMBER
(
)
STREET ADDRESS
CITY
STATE
ZIP CODE
Dated __________________________, _________
(insert date)
______________________________________
APPLICANT’S SIGNATURE
STATE OF______________________________
COUNTY OF____________________________
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that ___________________
_______________________________ personally known to me to be the same person whose name is subscribed to the
foregoing Information Exchange Authorization, appeared before me in person and acknowledged that he/she signed such
authorization at his/her free and voluntary act and that the statements in such authorization are true.
Given under my hand and notarial seal on __________________________, _________
(insert date)
______________________________________
SIGNATURE OF NOTARY
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737
VR 161.8 (rev. 1/16)
IL482-1020
Printed by Authority of the State of Illinois
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