I, _________________________________________________, state the following:

(present name)

(first)

(middle)

(last)

Sibling's (my)

birth name (if known)

(first)

(middle)

(last)

Date of birth

Sex

Race

City and state of birth

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 siblings(s) having a common birth parent with non-surrendered birth sibling (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 parent(s)

Race

(first)

(middle)

(maiden)

(last)

Race

(first)

(middle)

(last)

My sibling was

surrendered for adoption to

(name of agency)

City and state of agency

Date

(approximate)

Other identifying information

(Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, then you must submit a certified copy of your birth certificate and (iii) you must submit with the registration a certified copy of the common birth parent(s) death certificate(s) which parent(s) did not file a denial of information exchange.)