Michigan > Local County > Oakland > Family Division
Parents Consent Or Denial To Release Information To Adult Adoptee DHS-1919 - Michigan
| Parents Consent Or Denial To Release Information To Adult Adoptee Form. This is a Michigan form and can be used in Family Division Oakland Local County . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
PARENT'S CONSENT/DENIAL TO RELEASE INFORMATION TO ADULT ADOPTEE Michigan Department of Human Services CENTRAL ADOPTION REGISTRY · A new statement may be sent to the Central · Adoption Registry any time to withdraw a previous consent or to withdraw a previous denial. Release of identifying information will be based on the most · recent statement on file in the Central Adoption Registry. A parent giving consent should send to the Central Adoption Registry a new statement if either his/her name or address changes. A separate form must be filled out for each child for whom you are giving consent/denial. Send the original copy to the Central Adoption Registry, address below: MICHIGAN DEPARTMENT OF HUMAN SERVICES CENTRAL ADOPTION REGISTRY PO BOX 30037 LANSING MI 48909 · I state that I am the father mother of the child described below. I hereby give consent do not give consent* to the release of my name and address to this child when he/she is 18 years of age or older. (*If the denial box is checked, the parent may provide an explanation as to why he/she does not wish to release name and address). Reason: CHILD INFORMATION: Birth Date Child's Full Name at Birth (Last, First, Middle) Child's Birth Date (Month/Day/Year) Child's City of Birth Child's County of Birth Child's State of Birth Child's Birth Mother's Name When Parental Rights were Released or Terminated (Last, First, Middle) PARENT INFORMATION: FOR OFFICE USE ONLY My Current Name (Last, First, Middle) My Birth Date (Mo., Day, Yr.) My Current Address (Street Number and Name) Apartment or Lot Number City State Zip Code Telephone Number ( Signature Date ) Adoptee's Birth Name (Last, First, Middle) The Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your county. AUTHORITY: MCLA 710.68. COMPLETION: Voluntary. PENALTY: None DISTRIBUTION: ORIGINAL - Michigan Department of Human Services Central Adoption Registry P.O. Box 30037 Lansing, Michigan 48909 COPY Keep for your records. DHS-1919 (Rev. 5-05) Previous edition obsolete. MS Word 1 American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
