Illinois > Statewide > Miscellaneous
Petition For Appointment Of Confidential Intermediary - Illinois
| Petition For Appointment Of Confidential Intermediary Form. This is a Illinois form and can be used in Miscellaneous Statewide . |
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IN THE CIRCUIT COURT OF ______________ COUNTY, ILLINOIS In the Matter of the Petition of ________________________ For appointment of Confidential Intermediary ) ) ) ) ) ) No. _______________________ PETITION FOR APPOINTMENT OF A CONFIDENTIAL INTERMEDIARY Comes now __________________________________ petitioning this Court for the appointment of a Confidential Intermediary pursuant to 750 ILCS 50/18.3a and in support of this petition states as follows: 1. I am: (select one) an adopted person 21 years of age or over; or a "surrendered person" 21 years of age or over (Note: A "surrendered person" is a person who was never adopted but whose birth parents' rights were surrendered or terminated); or an adoptive parent of an adopted person under the age of 21; Please complete the following information, if known: Date of adoption: Adoption case number: ________________________ ________________________ or a legal guardian of an adopted or surrendered person under the age of 21; please attach a copy of the order appointing the Petitioner the legal guardian of the adopted or surrendered person; or a birth parent of an adopted or surrendered person 21 years of age or over; or an adult child of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or an adoptive parent of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or a legal guardian of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or a surviving spouse of a deceased adopted or surrendered person; please attach documents establishing the relationship between the Petitioner and the deceased adopted or surrendered person as well as a copy of the death certificate for the deceased adopted or surrendered person; or 1 American LegalNet, Inc. www.FormsWorkFlow.com an adult birth sibling of an adopted or surrendered person whose common birth parent is deceased and whose adopted or surrendered birth sibling is 21 years of age or over; please attach documents establishing the relationship between the Petitioner and the deceased birth parent as well as a copy of the death certificate for the deceased birth parent; or an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over; please attach copies of the deceased birth parent's death certificate and all documents establishing the relationship between the Petitioner and the deceased birth parent. 2. That ______________________________________________ is an adopted or surrendered person (name of adopted or surrendered person or child's name at birth) having a date of birth of _______________, and on the date of filing this Petition said adopted or surrendered person is _____ years of age. (age) Since the date of my adoption or date that I became a surrendered person, my name has been legally changed by marriage (please attach a copy of a marriage certificate) or by legal change of name (please attach a certified copy of order changing name). Strike if not applicable. 3. ______________________________ was adopted by ______________________________ (name of adopted person) on or about ________________ in_________ County, Illinois, and named ______________. 4. That the Petitioner seeks the appointment of a Confidential Intermediary for the purpose of (select all that apply): exchanging medical information with one or more mutually consenting biological relatives of the adopted or surrendered person; and/or obtaining identifying information about one or more mutually consenting biological relatives of the adopted or surrendered person; and/or arranging contact with one or more mutually consenting biological relatives of the adopted or surrendered person. 5. The Petitioner seeks the following biological relative(s) (select all that apply): any/all living birth relatives 21 years of age or over birth son(s) or daughter(s) 21 years of age or over birth mother birth father birth sibling 21 years of age or over other person 21 years of age or over (please identify): _________________ 6. If the Petitioner is: · an adult child, adoptive parent, legal guardian or surviving spouse of a deceased adopted or surrendered person (strike as applicable); or · an adult birth sibling of an adopted or surrendered person whose common birth parent is deceased and whose adopted or surrendered birth sibling is 21 years of age or over; or · an adult sibling of a deceased birth parent whose surrendered child is 21 years of age or over, disclosure of the requested information is of greater benefit than nondisclosure because: 2 American LegalNet, Inc. www.FormsWorkFlow.com Please explain in detail why you are filing the petition. Attach additional pages or documents as needed. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 7. The Petitioner has been entered into the Illinois Adoption Registry and Medical Information Exchange as evidenced by the attached verification of registration letter. NOTICE Except as stated below, the Petitioner understands that the appointed Confidential Intermediary will not have access to the following: personal health information protected by the Standards for Privacy of Individually Identifiable Health Information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); medical records; financial records; credit records; banking records; home studies; attorney's records; or other personal records. The Petitioner also understands the public or private adoption agency shall only disclose to the Confidential Intermediary the full name, the date of birth, place of birth, last known address and last known telephone number of the sought after relative, or if applicable, of the children or siblings of the sought after relative. If the Petitioner is an adult a
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