750 ILCS 50/18.2
BIRTH PARENT REGISTRATION IDENTIFICATION
(Insert all known information)
I,..... , state that I am the...... (mother or father) of the following child:
Child's original name:..... (first)..... (middle)..... (last),..... (hour of birth),..... (date of birth), ..... (city and state of birth),..... (name of hospital).
Father's full name:...... (first)...... (middle)..... (last),..... (date of birth),..... (city and state of birth).
Name of mother inserted on birth certificate:..... (first) ..... (middle)..... (last),..... (race),..... (date of birth),...... (city and state of birth).
That I surrendered my child to:............. (name of agency), ..... (city and state of agency),..... (approximate date child surrendered).
That I placed my child by private adoption:..... (date), ...... (city and state).
Name of adoptive parents, if known:......
Other identifying information:.....
........................
(Signature of parent)
............ ........................
(date)
(printed name of parent)
ADOPTED PERSON
REGISTRATION IDENTIFICATION
(Insert all known information)
I,..... , state the following:
Adopted Person's present name:..... (first)..... (middle)..... (last).
Adopted Person's name at birth (if known):..... (first) ..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex),..... (race).
Name of adoptive father:..... (first)..... (middle)..... (last),..... (race).
Maiden name of adoptive mother:..... (first)..... (middle)..... (last),..... (race).
Name of birth mother (if known):..... (first)..... (middle)..... (last),..... (race).
Name of birth father (if known):..... (first)..... (middle)..... (last),..... (race).
Name(s) at birth of sibling(s) having a common birth parent with adoptee (if known):..... (first)..... (middle) ..... (last),..... (race), and name of common birth parent:..... (first)..... (middle)..... (last), ..... (race).
I was adopted through:..... (name of agency).
I was adopted privately:..... (state "yes" if known).
I was adopted in..... (city and state),..... (approximate date).
Other identifying information:.............
......................
(signature of adoptee)
............ ........................
(date)
(printed name of adoptee)
SURRENDERED PERSON REGISTRATION
IDENTIFICATION
(Insert all known information)
I,..... , state the following:
Surrendered Person's present name:..... (first)..... (middle)..... (last).
Surrendered Person's name at birth (if known):..... (first)..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex), ..... (race).
Name of guardian father:..... (first)..... (middle)..... (last),..... (race).
Maiden name of guardian mother:..... (first)..... (middle)..... (last),..... (race).
Name of birth mother (if known):..... (first)..... (middle)..... (last)..... (race).
Name of birth father (if known):..... (first)..... (middle)..... (last),..... (race).
Name(s) at birth of sibling(s) having a common birth parent with surrendered person (if known):..... (first) ..... (middle)..... (last),..... (race), and name of common birth parent:..... (first)..... (middle) ..... (last),..... (race).
I was surrendered for adoption to:..... (name of agency).
I was surrendered for adoption in..... (city and state),.....
(approximate date).
Other identifying information:............
................................
(signature of surrendered person)
.......... ........................
(date)
(printed name of person surrendered for adoption)
REGISTRATION IDENTIFICATION FORM
FOR SURVIVING RELATIVES OF DECEASED BIRTH PARENTS
(Insert all known information)
I,..... , state the following:
Name of deceased birth parent at time of surrender:
Deceased birth parent's date of birth:
Deceased birth parent's date of death:
Adopted or surrendered person's name at birth (if known):
..... (first)..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex), ..... (race).
My relationship to the adopted or surrendered person (check one): (birth parent's non-surrendered child) (birth parent's parent) (birth parent's sister) (birth parent's brother).
If you are a non-surrendered child of the birth parent, provide name(s) at birth and age(s) of non-surrendered siblings having a common parent with the birth parent. If more than one sibling, please give information requested below on reverse side of this form. If you are a sibling or parent of the birth parent, provide name(s) at birth and age(s) of the sibling(s) of the birth parent. If more than one sibling, please give information requested below on reverse side of this form.
Name (First)..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex), ..... (race).
Name(s) of common parent(s) (first)..... (middle)..... (last),..... (race), (first)..... (middle)..... (last),..... (race).
My birth sibling/child of my brother/child of my sister/ was surrendered for adoption to..... (name of agency) City and state of agency..... Date..... (approximate) Other identifying information..... (Please note that you must: (i) be at least 21 years of age to register; (ii) submit with your registration a certified copy of the birth parent's birth certificate; (iii) submit a certified copy of the birth parent's death certificate; and (iv) if you are a non-surrendered birth sibling or a sibling of the deceased birth parent, also submit a certified copy of your birth certificate with this registration. No application from a surviving relative of a deceased birth parent can be accepted if the birth parent filed a Denial of Information Exchange prior to his or her death.)
................................
(signature of birth parent's surviving relative)
....... .................
(date)
(printed name of birth parent's surviving relative)
REGISTRATION IDENTIFICATION FORM FOR SURVIVING RELATIVES OF DECEASED ADOPTED OR SURRENDERED PERSONS
(Insert all known information)
I,..... , state the following:
Adopted or surrendered person's name at birth (if known):
(first)..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex), ..... (race).
Adopted or surrendered person's date of death: My relationship to the deceased adopted or surrendered person(check one): (adoptive mother) (adoptive father) (adult child) (surviving spouse).
If you are an adult child or surviving spouse of the adopted or surrendered person, provide name(s) at birth and age(s) of the children of the adopted or surrendered person. If the adopted or surrendered person had more than one child, please give information requested below on reverse side of this form.
Name (First)..... (middle)..... (last),..... (birth date),..... (city and state of birth),...... (sex), ..... (race).
Name(s) of common parent(s) (first)..... (middle)..... (last),..... (race), (first)..... (middle)..... (last),..... (race).
My child/parent/deceased spouse was surrendered for adoption to..... (name of agency) City and state of agency ..... Date..... (approximate) Other identifying information..... (Please note that you must: (i) be at least 21 years of age to register; (ii) submit with your registration a certified copy of the adopted or surrendered person's death certificate; (iii) if you are the child of a deceased adopted or surrendered person, also submit a certified copy of your birth certificate with this registration; and (iv) if you are the surviving wife or husband of a deceased adopted or surrendered person, also submit a copy of your marriage certificate with this registration. No application from a surviving relative of a deceased adopted or surrendered person can be accepted if the adopted or surrendered person filed a Denial of Information Exchange prior to his or her death.)
................................
(signature of adopted or surrendered person's surviving relative)
....... .................
(date)
(printed name of adopted person's surviving relative)
INFORMATION EXCHANGE AUTHORIZATION
I,..... , state that I am the person who completed the Registration Identification; that I am of the age of..... years; that I hereby authorize the Department of Public Health to give to the following person(s) (birth mother) (birth father) (birth sibling) (adopted or surrendered person) (adoptive mother) (adoptive father) (legal guardian of an adopted or surrendered person) (birth grandparent) (birth aunt) (birth uncle) (adult child of a deceased adopted or surrendered person) (surviving spouse of a deceased adopted or surrendered person) (all eligible relatives) the following (please check the information authorized for exchange):
[ ] 1. Only my name and last known address.
[ ] 2. A copy of my Illinois Adoption Registry Application.
[ ] 3. A non-certified copy of the adopted or surrendered person's original certificate of live birth (check only if you are an adopted or surrendered person or the surviving adult child or surviving spouse of a deceased adopted or surrendered person).
[ ] 4. A copy of my completed medical questionnaire.
I am fully aware that I can only be supplied with information about an individual or individuals who have duly executed an Information Exchange Authorization that has not been revoked or, if I am an adopted or surrendered person, from a birth parent who completed a Birth Parent Preference Form and did not prohibit the release of his or her identity to me; that I can be contacted by writing to:..... (own name or name of person to contact) (address) (phone number).
NOTE: New IARMIE registrants who do not complete a Medical Information Exchange Questionnaire and release a copy of their questionnaire to at least one Registry applicant must pay a $15 registration fee.
Dated (insert date).
..............
(signature)
DENIAL OF INFORMATION EXCHANGE
I,..... , state that I am the person who completed the Registration Identification; that I am of the age of..... years; that I hereby instruct the Department of Public Health not to give any identifying information about me to the following person(s) (birth mother) (birth father) (birth sibling) (adopted or surrendered person) (adoptive mother) (adoptive father) (legal guardian of an adopted or surrendered person) (birth grandparent) (birth aunt) (birth uncle) (adult child of a deceased adopted or surrendered person) (surviving spouse of a deceased adopted or surrendered person) (all eligible relatives).
I do/do not (circle appropriate response) authorize the Registry to release a copy of my completed Medical Information Exchange Questionnaire to qualified Registry applicants. NOTE: New IARMIE registrants who do not complete a Medical Information Exchange Questionnaire and release a copy of their questionnaire to at least one Registry applicant must pay a $15 registration fee. Birth parents filing a Denial of Information Exchange are advised that, under Illinois law, an adult adopted person may initiate a search for a birth parent who has filed a Denial of Information Exchange or Birth Parent Preference Form on which Option E was selected through the State confidential intermediary program once 5 years have elapsed since the filing of the Denial of Information Exchange or Birth Parent Preference Form.
Dated (insert date).
...............
(signature)
In recognition of the basic right of all persons to access their birth records, Illinois law now provides for the release of original birth certificates to adopted and surrendered persons 21 years of age or older upon request. While many birth parents are comfortable sharing their identities or initiating contact with their birth sons and daughters once they have reached adulthood, Illinois law also recognizes that there may be unique situations where a birth parent might have a compelling reason for not wishing to establish contact with a birth son or birth daughter or for not wishing to release identifying information that appears on the original birth certificate of a birth son or birth daughter who has reached adulthood. The Illinois Adoption Registry and Medical Information Exchange (IARMIE) has therefore established the attached form to allow birth parents to express their preferences regarding contact; and, if their birth child was born on or after January 1, 1946, to express their wishes regarding the sharing of identifying information listed on the original birth certificate with an adult adopted or surrendered person who has reached the age of 21 or his or her surviving relatives.
In selecting one of the 5 options below, birth parents should keep in mind that the decision to deny an adult adopted or surrendered person access to identifying information on his or her original birth record and/or information about genetically-transmitted diseases is an important decision that may impact the adopted or surrendered person's life in many ways. A request for anonymity on this form only pertains to information that is provided to an adult adopted or surrendered person or his or her surviving relatives through the Registry. This will not prevent the disclosure of identifying information that may be available to the adoptee through his or her adoptive parents and/or other means available to him or her. Birth parents who would prefer not to be contacted by their surrendered son or daughter are strongly urged to complete both the Non-Identifying Information Section included on the final page of the attached form and the Medical Questionnaire in order to provide their surrendered son or daughter with the background information he or she may need to better understand his or her origins. Birth parents whose birth son or birth daughter is under 21 years of age at the time of the completion of this form are reminded that no original birth certificate will be released by the IARMIE before an adoptee has reached the age of 21. Should you need additional assistance in completing this form, please contact the agency that handled the adoption, if applicable, or the Illinois Adoption Registry and Medical Information Exchange at 877-323-5299.
After careful consideration, I have made the following decision regarding contact with my birth son/birth daughter, (insert birth son's/birth daughter's name at birth, if applicable)...... , who was born in (insert city/town of birth) ...... on (insert date of birth)...... and the release of my identifying information as it appears on his/her original birth certificate when he/she reaches the age of 21, and I have chosen Option...... (insert A, B, C, D, or E, as applicable). I realize that this form must be accompanied by a completed IARMIE application form as well as a Medical Information Exchange Questionnaire or the $15 registration fee. I am also aware that I may revoke this decision at any time by completing a new Birth Parent Preference Form and filing it with the IARMIE. I understand that it is my responsibility to update the IARMIE with any changes to contact information provided below. I also understand that, while preferences regarding the release of identifying information through the Registry are binding unless the law should change in the future, any selection I have made regarding my preferred method of contact is not
.............................................................
(Signature/Date)
(Please insert your signature and today's date above, as well as under your chosen option, A, B, C, D, or E below.)
Option A. My birth son or birth daughter was born on or after January 1, 1946, and I agree to the release of my identifying information as it appears on my birth son's/birth daughter's original birth certificate, OR my birth son or birth daughter was born prior to January 1, 1946. I would welcome direct contact with my birth son/birth daughter when he or she has reached the age of 21. In addition, before my birth son or birth daughter has reached the age of 21 or in the event of his or her death, I would welcome contact with the following relatives of my birth child (circle all that apply): adoptive mother, adoptive father, surviving spouse, surviving adult child. I wish to be contacted at the following mailing address, email address or phone number:
............................................................
............................................................
............................................................
............................................................
(Signature/Date)
Option B. My birth son or birth daughter was born on or after January 1, 1946, and I agree to the release of my identifying information as it appears on my birth son's/birth daughter's original birth certificate, OR my birth son or birth daughter was born prior to January 1, 1946. I would welcome contact with my birth son/birth daughter when he or she has reached the age of 21. In addition, before my birth son or birth daughter has reached the age of 21 or in the event of his or her death, I would welcome contact with the following relatives of my birth child (circle all that apply): adoptive mother, adoptive father, surviving spouse, surviving adult child. I would prefer to be contacted through the following person. (Insert name and mailing address, email address or phone number of chosen contact person.)
............................................................
............................................................
(Signature/Date)
Option C. My birth son or birth daughter was born on or after January 1, 1946, and I agree to the release of my identifying information as it appears on my birth son's/birth daughter's original birth certificate, OR my birth son or birth daughter was born prior to January 1, 1946. I would welcome contact with my birth son/birth daughter when he or she has reached the age of 21. In addition, before my birth son or birth daughter has reached the age of 21 or in the event of his or her death, I would welcome contact with the following relatives of my birth child (circle all that apply): adoptive mother, adoptive father, surviving spouse, surviving adult child. I would prefer to be contacted through the Illinois Confidential Intermediary Program (please call 800-526-9022 for additional information) or through the agency that handled the adoption. (Insert agency name, address and phone number, if applicable.)
............................................................
............................................................
(Signature/Date)
Option D. My birth son or birth daughter was born on or after January 1, 1946, and I agree to the release of my identifying information as it appears on my birth son's/birth daughter's original birth certificate when he or she has reached the age of 21, OR my birth son or birth daughter was born prior to January 1, 1946. I would prefer not to be contacted by my birth son/birth daughter or his or her adoptive parents or surviving relatives.
............................................................
(Signature/Date)
Option E. My birth son or birth daughter was born on or after January 1, 1946, and I wish to prohibit the release of my (circle ALL applicable options) first name, last name, last known address, birth son/birth daughter's last name (if last name listed is same as mine), as they appear on my birth son's/birth daughter's original birth certificate and do not wish to be contacted by my birth son/birth daughter when he or she has reached the age of 21. If there were any special circumstances that played a role in your decision to remain anonymous which you would like to share with your birth son/birth daughter, please list them in the space provided below (optional).
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............................................................
I understand that, although I have chosen to prohibit the release of my identity on the non-certified copy of the original birth certificate released to my birth son/birth daughter, he or she may request that a court-appointed confidential intermediary contact me to request updated medical information and/or confirm my desire to remain anonymous once 5 years have elapsed since the signing of this form; at the time of this subsequent search, I wish to be contacted through the person named below. (Insert in blank area below the name and phone number of the contact person, or leave it blank if you wish to be contacted directly.) I also understand that this request for anonymity shall expire upon my death.
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............................................................
(Signature/Date)
NOTE: A copy of this form will be forwarded to your birth son or birth daughter should he or she file a request for his or her original birth certificate with the IARMIE. However, if you have selected Option E, identifying information, per your specifications above, will be deleted from the copy of this form forwarded to your birth son or daughter during your lifetime. In the event that an adopted or surrendered person is deceased, his or her surviving adult children may request a copy of the adopted or surrendered person's original birth certificate providing they have registered with the IARMIE; the copy of this form and the non-certified copy of the original birth certificate forwarded to the surviving child of the adopted or surrendered person shall be redacted per your specifications on this form during your lifetime.
Non-Identifying Information Section
I wish to voluntarily provide the following non-identifying information to my birth son or birth daughter:
My age at the time of my child's birth was.........
My race is best described as:..........................
My height is:.........
My body type is best described as (circle one): slim, average, muscular, a few extra pounds, or more than a few extra pounds.
My natural hair color is/was:..................
My eye color is:..................
My religion is best described as:..................
My ethnic background is best described as:..................
My educational level is closest to (circle applicable response): completed elementary school, graduated from high school, attended college, earned bachelor's degree, earned master's degree, earned doctoral degree.
My occupation is best described as..................
My hobbies include..................
My interests include..................
My talents include..................
In addition to my surrendered son or daughter, I also am the biological parent of (insert number)....... boys and (insert number)....... girls, of whom (insert number)....... are still living.
The relationship between me and my child's birth mother/birth father would best be described as (circle appropriate response): husband and wife, ex-spouses, boyfriend and girlfriend, casual acquaintances, other (please specify) ..............
REQUEST FOR A NON-CERTIFIED COPY OF AN ORIGINAL BIRTH CERTIFICATE
I, (requesting party's full name)..... , hereby request a non-certified copy of (check appropriate option)..... my original birth certificate..... the original birth certificate of my deceased adopted or surrendered parent..... the original birth certificate of my deceased adopted or surrendered spouse (insert deceased parent's/deceased spouse's name at adoption)...... I/my deceased parent/my deceased spouse was born in (insert city and county of adopted or surrendered person's birth)..... on..... (insert adopted or surrendered person's date of birth). In the event that one or both of my/my deceased parent's/my deceased spouse's birth parents has requested that their identity not be released to me/to my deceased parent/to my deceased spouse, I wish to (check appropriate option)..... a. receive a non-certified copy of the original birth certificate from which identifying information pertaining to the birth parent who requested anonymity has been deleted; or..... b. I do not wish to receive an altered copy of the original birth certificate.
Dated (insert date).
...................
(signature)
State of..............
County of.............
I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that............... personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (he or she) signed such certificate as (his or her) free and voluntary act and that the statements in such certificate are true.
Given under my hand and notarial seal on (insert date).
.........................
(signature)
State of..........
County of.........
I, a Notary Public, in and for the said County, in the State aforesaid, do hereby certify that..... personally known to me to be the same person whose name is subscribed to the foregoing certificate of acknowledgement, appeared before me in person and acknowledged that (he or she) signed such certificate as (his or her) free and voluntary act and that the statements in such certificate are true.
Given under my hand and notarial seal on (insert date).
.......................
(signature)
750 ILCS 50/18.2