Ohio > County (Court Of Common Pleas) > Wood > Probate > Adoptions
Authorization For Release Of Information 19.12 - Ohio
| Authorization For Release Of Information Form. This is a Ohio form and can be used in Adoptions Probate Wood County (Court Of Common Pleas) . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge IN THE MATTER OF THE ADOPTION OF:________________________________________________________ (Name after adoption) Case No: ______________________ Date:______________________ AUTHORIZATION FOR RELEASE OF INFORMATION I, _____________________________________________, of ___________________________________ (Petitioner) (Address) (Address) __________________________________________________________ do hereby authorize the following Wood 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 Wood County Probate Court. I understand that the Wood 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 Wood 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. ____________________________________ ______________________________________ Signature Witness --------------------------------------------------------------------------------TO BE COMPLETED BY EACH AGENCY (Please check appropriate space and sign. If a record is located, attach record/information to this form.) Record Located Record Located Record Located No Record Located Wood County Adult Protective Services No Record Located Wood County Children Services Board No Record Located Wood County Sheriff's Department FORM 19.12 - AUTHORIZATION FOR RELEASE OF INFORMATION Crensch$\forms\19.12.doc 1912 5/15/01 American LegalNet, Inc. www.USCourtForms.com
|
|||||||
