Release Of Information Authorization Adult Adoptee {FIA-1920}

RELEASE OF INFORMATION AUTHORIZATION ADULT ADOPTEE State of Michigan ­ Department of Human Services I hereby authorize the adoption agency and/or the probate court named below, in accordance with P.A. 288 of 1939, Chapter 10, to release, upon request, my name and address to: My Biological Parent(s) CURRENT INFORMATION Current Name (Last, First Middle Birth Date Month Day Apartment Number Year An Adult Brother/Sister Current Address (Street Number and Name) City State Zip Code Telephone Number A/C ( ) ADOPTION INFORMATION Adoptive Name (Last, First, Middle) Name Before Adoption (If Known) Adoptive Mother's Name Adoptive Father's Name Birth Mother's Name Birth Father's Name Name of Probate Court Name of Placing Agency Additional Comments Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. DISTRIBUTION: 1st Copy ­ Probate Court that Finalized Adoption 2nd Copy ­ Adoption Agency 3rd Copy ­ Keep for Your Records Adult Adoptee's Signature AUTHORITY: MCLA 710.68. COMPLETION: Voluntary. PENALTY: None. Date DHS-1920 (Rev. 8-05) Previous edition may be used. MS Word 1 American LegalNet, Inc. www.FormsWorkFlow.com