093_HB2136eng HB2136 Engrossed LRB093 07705 LCB 07893 b 1 AN ACT concerning adoption. 2 Be it enacted by the People of the State of Illinois, 3 represented in the General Assembly: 4 Section 5. The Adoption Act is amended by changing 5 Section 18.2 as follows: 6 (750 ILCS 50/18.2) (from Ch. 40, par. 1522.2) 7 Sec. 18.2. Forms. 8 (a) The form of the Birth Parent Registration 9 Identification Form shall be substantially as follows: 10 BIRTH PARENT REGISTRATION IDENTIFICATION 11 (Insert all known information) 12 I, ....., state that I am the ...... (mother or father) of 13 the following child: 14 Child's original name: ..... (first) ..... (middle) ..... 15 (last), ..... (hour of birth), ..... (date of 16 birth), ..... (city and state of birth), ..... (name 17 of hospital). 18 Father's full name: ...... (first) ...... (middle) ..... 19 (last), ..... (date of birth), ..... (city and state 20 of birth). 21 Name of mother inserted on birth certificate: ..... 22 (first) ..... (middle) ..... (last), ..... (race), 23 ..... (date of birth), ...... (city and state of 24 birth). 25 That I surrendered my child to: ............. (name of 26 agency), ..... (city and state of agency), ..... 27 (approximate date child surrendered). 28 That I placed my child by private adoption: ..... (date), 29 ...... (city and state). 30 Name of adoptive parents, if known: ...... 31 Other identifying information: ..... HB2136 Engrossed -2- LRB093 07705 LCB 07893 b 1 ........................ 2 (Signature of parent) 3 ............ ........................ 4 (date) (printed name of parent) 5 (b) The form of the Adopted Person Registration 6 Identification shall be substantially as follows: 7 ADOPTED PERSON 8 REGISTRATION IDENTIFICATION 9 (Insert all known information) 10 I, ....., state the following: 11 Adopted Person's present name: ..... (first) ..... 12 (middle) ..... (last). 13 Adopted Person's name at birth (if known): ..... (first) 14 ..... (middle) ..... (last), ..... (birth date), 15 ..... (city and state of birth), ...... (sex), ..... 16 (race). 17 Name of adoptive father: ..... (first) ..... (middle) 18 ..... (last), ..... (race). 19 Maiden name of adoptive mother: ..... (first) ..... 20 (middle) ..... (last), ..... (race). 21 Name of birth mother (if known): ..... (first) ..... 22 (middle) ..... (last), ..... (race). 23 Name of birth father (if known): ..... (first) ..... 24 (middle) ..... (last), ..... (race). 25 Name(s) at birth of sibling(s) having a common birth 26 parent with adoptee (if known): ..... (first) ..... 27 (middle) ..... (last), ..... (race), and name of 28 common birth parent: ..... (first) ..... (middle) 29 ..... (last), ..... (race). 30 I was adopted through: ..... (name of agency). 31 I was adopted privately: ..... (state "yes" if known). 32 I was adopted in ..... (city and state), ..... (approximate 33 date). 34 Other identifying information: ............. HB2136 Engrossed -3- LRB093 07705 LCB 07893 b 1 ...................... 2 (signature of adoptee) 3 ........... ......................... 4 (date) (printed name of adoptee) 5 (c) The form of the Surrendered Person Registration 6 Identification shall be substantially as follows: 7 SURRENDERED PERSON REGISTRATION 8 IDENTIFICATION 9 (Insert all known information) 10 I, ....., state the following: 11 Surrendered Person's present name: ..... (first) ..... 12 (middle) ..... (last). 13 Surrendered Person's name at birth (if known): ..... 14 (first) ..... (middle) ..... (last), .....(birth 15 date), ..... (city and state of birth), ...... 16 (sex), ..... (race). 17 Name of guardian father: ..... (first) ..... (middle) 18 ..... (last), ..... (race). 19 Maiden name of guardian mother: ..... (first) ..... 20 (middle) ..... (last), ..... (race). 21 Name of birth mother (if known): ..... (first) ..... 22 (middle) ..... (last) ..... (race). 23 Name of birth father (if known): ..... (first) ..... 24 (middle) ..... (last), .....(race). 25 Name(s) at birth of sibling(s) having a common birth 26 parent with surrendered person (if known): ..... 27 (first) ..... (middle) ..... (last), ..... (race), 28 and name of common birth parent: ..... (first) ..... 29 (middle) ..... (last), ..... (race). 30 I was surrendered for adoption to: ..... (name of agency). 31 I was surrendered for adoption in ..... (city and state), 32 ..... (approximate date). 33 Other identifying information: ............ 34 ................................ HB2136 Engrossed -4- LRB093 07705 LCB 07893 b 1 (signature of surrendered person) 2 ............ ...................... 3 (date) (printed name of person 4 surrendered for adoption) 5 (d) The form of the Information Exchange Authorization 6 shall be substantially as follows: 7 INFORMATION EXCHANGE AUTHORIZATION 8 I, ....., state that I am the person who completed the 9 Registration Identification; that I am of the age of ..... 10 years; that I hereby authorize the Department of Public 11 Health to give to my (birth parent) (birth sibling) 12 (surrendered child) the following (please check the 13 information authorized for exchange): 14 [ ] 1. Only my name and last known address. 15 [ ] 2. A copy of my Illinois Adoption Registry 16 Application. 17 [ ] 3. A copy of the original certificate of live 18 birth. 19 I am fully aware that I can only be supplied with any 20 information about my (birth parent) (birth sibling) 21 (surrendered child) if such person has duly executed an 22 Information Exchange Authorization for such information which 23 has not been revoked; that I can be contacted by writing to: 24 ..... (own name or name of person to contact) (address) 25 (phone number). 26 Dated (insert date). 27.......................... 28(witness)(signature) 29 (e) The form of the Denial of Information Exchange shall 30 be substantially as follows: 31 DENIAL OF INFORMATION EXCHANGE 32 I, ....., state that I am the person who completed the 33 Registration Identification; that I am of the age of ..... HB2136 Engrossed -5- LRB093 07705 LCB 07893 b 1 years; that I hereby instruct the Department of Public Health 2 not to give any identifying information about me to my (birth 3 parent) (birth sibling) (surrendered child); that I do not 4 wish to be contacted. 5 Dated (insert date). 6............................ 7(witness)(signature) 8 (f) The Information Exchange Authorization and the 9 Denial of Information Exchange shall be acknowledged by the 10 birth parent, birth sibling, adopted or surrendered person, 11 adoptive parent, or legal guardian before a notary public, in 12 form substantially as follows: 13 State of .............. 14 County of ............. 15 I, a Notary Public, in and for the said County, in the 16 State aforesaid, do hereby certify that ............... 17 personally known to me to be the same person whose name is 18 subscribed to the foregoing certificate of acknowledgement, 19 appeared before me in person and acknowledged that (he or 20 she) signed such certificate as (his or her) free and 21 voluntary act and that the statements in such certificate are 22 true. 23 Given under my hand and notarial seal on (insert date). 24 ......................... 25 (signature) 26 (g) When the execution of an Information Exchange 27 Authorization or a Denial of Information Exchange is 28 acknowledged before a representative of an agency, such 29 representative shall have his signature on said Certificate 30 acknowledged before a notary public, in form substantially as 31 follows: 32 State of.......... 33 County of......... HB2136 Engrossed -6- LRB093 07705 LCB 07893 b 1 I, a Notary Public, in and for the said County, in the 2 State aforesaid, do hereby certify that ..... personally 3 known to me to be the same person whose name is subscribed to 4 the foregoing certificate of acknowledgement, appeared before 5 me in person and acknowledged that (he or she) signed such 6 certificate as (his or her) free and voluntary act and that 7 the statements in such certificate are true. 8 Given under my hand and notarial seal on (insert date). 9 ....................... 10 (signature) 11 (h) When an Illinois Adoption Registry Application, 12 Information Exchange Authorization or a Denial of Information 13 Exchange is executed in a foreign country, the execution of 14 such document shall be acknowledged or affirmed before an 15 officer of the United States consular services. 16 (i) If the person signing an Information Exchange 17 Authorization or a Denial of Information is in the military 18 service of the United States, the execution of such document 19 may be acknowledged before a commissioned officer and the 20 signature of such officer on such certificate shall be 21 verified or acknowledged before a notary public or by such 22 other procedure as is then in effect for such division or 23 branch of the armed forces. 24 (j) The Department shall modify these forms as necessary 25 to implement the provisions of this amendatory Act of 1999 26 including creating Registration Identification Forms for 27 non-surrendered birth siblings, adoptive parents and legal 28 guardians. 29 (Source: P.A. 91-357, eff. 7-29-99; 91-417, eff. 1-1-00.) 30 Section 99. Effective date. This Act takes effect upon 31 becoming law.