Affidavit For Access To Adoption Record

STATE OF MINNESOTA COUNTY OF HENNEPIN DISTRICT COURT--JUVENILE DIVISION FOURTH JUDICIAL DISTRICT AFFIDAVIT AND ORDER FOR ADOPTION INFORMATION Name of Affiant (Completed forms may be faxed to (612) 317-6117 Attn: Records OR sent to Juvenile Justice Center- Records, 590 Park Ave, Minneapolis MN 55415) (person completing form):___________________________________________________________ Current Street Address: ____________________________________________________________________ City: ______________________________________ State: ____________ Zip Code: __________________ Phone Number of Affiant: (Home) ___________________________ (Cell) ____________________________ Name of Adopted Person: _______________________________ A/K/A: _____________________________ Adopted Person's Date of Birth: ___________________ Approximate Date of Adoption: _________________ Name of Adoptive Parent(s): ________________________________________________________________ Adoption Court File # (if known): ___________________ Your Relationship to adopted person: ____________ Document(s) requested: A certified copy of an adoption decree. # of copies requested ________. The fee is $16.00 per copy payable to district court. Other document: [Must Specify] ____________________________________________ Which is information required for the following purpose: Social Security Passport Birth Certificate Personal Reasons (provide explanation): ___________________________ ____________________________________________________________ Other (provide explanation): _____________________________________ ____________________________________________________________ I declare under penalty of perjury that everything I have stated in this document is true and correct. ___________________________________________ Affiant's Signature County and State where signed:_____________________________________ Dated: _______________________ ORDER Based upon the foregoing Affidavit and consistent with Minnesota law, the request is denied. the Clerk of the above-named Court is authorized and directed to deliver to said affiant _________________________________________________________________________________________________ __________________________________________________________________________________________________. Dated: __________________________ ________________________________________________________ Judge of District Court--Juvenile Division American LegalNet, Inc. www.FormsWorkFlow.com