I,

, state that I am the court appointed

(first)

(middle)

(last)

legal guardian of an

(check one)

adopted or

surrendered person under the age of 21.

or

(check one)

adopted or

surrendered person over the age of 21 who

requires my continuing guardianship.

(Please note that you must submit a certified court order of the guardianship.)

Adopted or surrendered

person's birth name (if known)

(first)

(middle)

(last)

Adopted or surrendered

person's adoptive name (if applicable)

(first)

(middle)

(last)

Adopted or surrendered person's

current name (if different than above)

(first)

(middle)

(last)

Date of birth

Hour of birth

a.m./p.m.

Sex

City and state of birth

Hospital of birth

Name of

birth mother

(first)

(middle)

(maiden if known)

(last)

Name of

birth father

(if known)

(first)

(middle)

(last)

Name of

adoptive mother

(first)

(middle)

(maiden)

(last)

Name of

adoptive father

(first)

(middle)

(last)

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

(first)

(middle)

(last)

(date of birth or approximate age)

City and state of birth

Race

Name(s) of common

birth parent(s)

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.  A competent adult adopted person must file his or her own registration.)

(signature of legal guardian)

(date)

(printed or typed name of legal guardian)

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

VR 161.5 (rev. 05/2000)

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