I,

, state the following:

(present name)      (first)

(middle)

(last)

Adoptive name

(first)

(middle)

(last)

Adopted person's

birth name (if known)

Race

(first)

(middle)

(last)

Date of birth

Sex

Hospital (if known)

City and state of birth

Name of adoptive father

Race

(if applicable)

(first)

(middle)

(last)

Name of adoptive mother

Race

(if applicable)

(first)

(middle)

(maiden)

(last)

I was adopted through

(name of agency)

(city and state of agency)

I was adopted privately

(state "yes" if known

I was adopted in

(city and state)

(approximate date)

Other identifying information

Name of

birth mother

Race

(if known)

(first)

(middle)

(maiden)

(last)

Name of

birth father

Race

(if known)

(first)

(middle)

(last)

Provide name(s) at birth and ages of sibling(s) having a common birth parent with adopted person (if known). If more than one sibling, please give information requested below on reverse side of this form.

(first)

(middle)

(last)

Date of birth

Sex

Race

(or approximate age)

City and state of birth

Name(s) of common birth parents(s)

Race

(first)

(middle)

(last)

Race

(first)

(middle)

(last)

(Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, you must submit a certified copy of your birth certificate.)

(signature of adopted person)

(date)

(printed or typed name of adopted person)