I,

, state the following

(first)

(middle)

(last)

I am the

adoptive parent of

Race

 (adoptive name)

(first)

(middle)

(last)

Date of birth

Sex

Hospital (if known)

City and state of birth

Name of

adoptive father

(first)

(middle)

(last)

Name of

adoptive mother

(first)

(middle)

(maiden)

(last)

Our/my adopted son/daughter was adopted

through

(approximate date)

(name of  agency)

(city and state of agency)

Adopted privately

(state "yes" if applicable)

Adopted person's

birth name (if known)

Race

(first)

(middle)

(last)

Name of

birth mother

Race

(if known)

(first)

(middle)

(maiden)

(last)

Name of

birth father

Race

(if known)

(first)

(middle)

(last)

 Other identifying information

Provide name(s) at birth and ages of siblings(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 parent(s)

Race

(first)

(middle)

(last)

Race

(first)

(middle)

(last)

(Please note that your registration expires when the adopted person attains the age of 21, unless guardianship extends beyond this time and you have submitted a certified court order of guardianship.  A competent adult adopted person must file his or her own registration.)

(signature of adoptive parent)

(date)

(printed or typed name of adoptive parent)

Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield IL 62702-5097

VR  161.4 (rev. 05/2000)

Printed by Authority of the State of Illinois P.O. # 30M 02/00