PROBATE COURT OF BUTLER COUNTY, OHIOIN THE MATTER OF THE ADOPTION OF(Name after adoption) CASE NO.AUTHORIZATION FOR RELEASE OF INFORMATIONI,, of(Petitioner)(Address)(address)do hereby authorize the following Butler County agencies: Adult Protective Services, Children Services Board and the Sheriff's Department to release all information regarding any child neglect, child abuse, adult abuse, adult neglect or criminal records that I may have with the agencies to the Butler County Probate Court. I understand that the Butler County Probate Court has requested this information from your agency. I further understand that all information released by your agency will be considered confidential by the Butler County Probate Court.Date of Birth Social Security Number Marital Status Previous Address Maiden Name Spouse's Name Name of Former Spouse(s) Name(s) of Child(ren)A.K.A.SignatureWitnessTO BE COMPLETED BY EACH AGENCY (Please check appropriate space and sign. If a record is located, attach record/information to this form.)Record LocatedNo Record LocatedButler County Adult Protective ServicesRecord LocatedNo Record LocatedButler County Children Services BoardRecord LocatedNo Record LocatedButler County Sheriff's Department3/98BCPC FORM 324 -AUTHORIZATION FOR RELEASE OF INFORMATION -ADOPTION2001 © American LegalNet, Inc.
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