Surrendered Person Registration Identification Form - Illinois

This fillable "Surrendered Person Registration Identification Form" is a document issued by the Illinois Department of Public Health specifically for Illinois residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Illinois Department of Public Health
SURRENDERED PERSON REGISTRATION IDENTIFICATION
(Enter all known information.)
I, ________________________________________________________, state the following:
(present name)
(first)
(middle)
(last)
Surrendered person’s
birth name
___________________________________________________________
(if known)
(first)
(middle)
(last)
Date of birth _________________________ Sex _________________ Race __________
City and state of birth ________________________________________________________
Name of
birth mother _______________________________________________ Race __________
(if known)
(first)
(middle)
(maiden)
(last)
Name of
birth father ________________________________________________ Race __________
(if known)
(first)
(middle)
(last)
I was surrendered for adoption to _______________________________________________
(name of agency)
City and state of agency _____________________________________ Date ___________
(approximate)
Other identifying information ___________________________________________________
__________________________________________________________________________
Name of
guardian father ____________________________________________ Race __________
(if applicable)
(first)
(middle)
(last)
Maiden name of
guardian mother ___________________________________________ Race __________
(if applicable)
(first)
(middle)
(maiden)
(last)
Provide name(s) at birth and ages of siblings(s) having a common birth parent with surrendered
person
If more than one sibling, please give information requested below on reverse
(if known).
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)
(maiden)
(last)
_____________________________________________ Race __________
(first)
(middle)
(last)
(Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, then you must submit a certified
copy of your birth certificate.)
_____________________________________
(signature of surrendered person)
_____________________________
_____________________________________
(date)
(printed or typed name of surrendered person)
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737
Illinois Department of Public Health
SURRENDERED PERSON REGISTRATION IDENTIFICATION
(Enter all known information.)
I, ________________________________________________________, state the following:
(present name)
(first)
(middle)
(last)
Surrendered person’s
birth name
___________________________________________________________
(if known)
(first)
(middle)
(last)
Date of birth _________________________ Sex _________________ Race __________
City and state of birth ________________________________________________________
Name of
birth mother _______________________________________________ Race __________
(if known)
(first)
(middle)
(maiden)
(last)
Name of
birth father ________________________________________________ Race __________
(if known)
(first)
(middle)
(last)
I was surrendered for adoption to _______________________________________________
(name of agency)
City and state of agency _____________________________________ Date ___________
(approximate)
Other identifying information ___________________________________________________
__________________________________________________________________________
Name of
guardian father ____________________________________________ Race __________
(if applicable)
(first)
(middle)
(last)
Maiden name of
guardian mother ___________________________________________ Race __________
(if applicable)
(first)
(middle)
(maiden)
(last)
Provide name(s) at birth and ages of siblings(s) having a common birth parent with surrendered
person
If more than one sibling, please give information requested below on reverse
(if known).
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)
(maiden)
(last)
_____________________________________________ Race __________
(first)
(middle)
(last)
(Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, then you must submit a certified
copy of your birth certificate.)
_____________________________________
(signature of surrendered person)
_____________________________
_____________________________________
(date)
(printed or typed name of surrendered person)
Illinois Department of Public Health, Division of Vital Records, 925 East Ridgely Ave., Springfield, IL 62702-2737

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