093_SB0118sam001
LRB093 04906 LCB 12292 a
1 AMENDMENT TO SENATE BILL 118
2 AMENDMENT NO. . Amend Senate Bill 118 by replacing
3 everything after the enacting clause with the following:
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),
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1 ..... (date of birth), ...... (city and state of
2 birth).
3 That I surrendered my child to: ............. (name of
4 agency), ..... (city and state of agency), .....
5 (approximate date child surrendered).
6 That I placed my child by private adoption: ..... (date),
7 ...... (city and state).
8 Name of adoptive parents, if known: ......
9 Other identifying information: .....
10 ........................
11 (Signature of parent)
12 ............ ........................
13 (date) (printed name of parent)
14 (b) The form of the Adopted Person Registration
15 Identification shall be substantially as follows:
16 ADOPTED PERSON
17 REGISTRATION IDENTIFICATION
18 (Insert all known information)
19 I, ....., state the following:
20 Adopted Person's present name: ..... (first) .....
21 (middle) ..... (last).
22 Adopted Person's name at birth (if known): ..... (first)
23 ..... (middle) ..... (last), ..... (birth date),
24 ..... (city and state of birth), ...... (sex), .....
25 (race).
26 Name of adoptive father: ..... (first) ..... (middle)
27 ..... (last), ..... (race).
28 Maiden name of adoptive mother: ..... (first) .....
29 (middle) ..... (last), ..... (race).
30 Name of birth mother (if known): ..... (first) .....
31 (middle) ..... (last), ..... (race).
32 Name of birth father (if known): ..... (first) .....
33 (middle) ..... (last), ..... (race).
34 Name(s) at birth of sibling(s) having a common birth
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1 parent with adoptee (if known): ..... (first) .....
2 (middle) ..... (last), ..... (race), and name of
3 common birth parent: ..... (first) ..... (middle)
4 ..... (last), ..... (race).
5 I was adopted through: ..... (name of agency).
6 I was adopted privately: ..... (state "yes" if known).
7 I was adopted in ..... (city and state), ..... (approximate
8 date).
9 Other identifying information: .............
10 ......................
11 (signature of adoptee)
12 ........... .........................
13 (date) (printed name of adoptee)
14 (c) The form of the Surrendered Person Registration
15 Identification shall be substantially as follows:
16 SURRENDERED PERSON REGISTRATION
17 IDENTIFICATION
18 (Insert all known information)
19 I, ....., state the following:
20 Surrendered Person's present name: ..... (first) .....
21 (middle) ..... (last).
22 Surrendered Person's name at birth (if known): .....
23 (first) ..... (middle) ..... (last), .....(birth
24 date), ..... (city and state of birth), ......
25 (sex), ..... (race).
26 Name of guardian father: ..... (first) ..... (middle)
27 ..... (last), ..... (race).
28 Maiden name of guardian mother: ..... (first) .....
29 (middle) ..... (last), ..... (race).
30 Name of birth mother (if known): ..... (first) .....
31 (middle) ..... (last) ..... (race).
32 Name of birth father (if known): ..... (first) .....
33 (middle) ..... (last), .....(race).
34 Name(s) at birth of sibling(s) having a common birth
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1 parent with surrendered person (if known): .....
2 (first) ..... (middle) ..... (last), ..... (race),
3 and name of common birth parent: ..... (first) .....
4 (middle) ..... (last), ..... (race).
5 I was surrendered for adoption to: ..... (name of agency).
6 I was surrendered for adoption in ..... (city and state),
7 ..... (approximate date).
8 Other identifying information: ............
9 ................................
10 (signature of surrendered person)
11 ............ ......................
12 (date) (printed name of person
13 surrendered for adoption)
14 (d) The form of the Information Exchange Authorization
15 shall be substantially as follows:
16 INFORMATION EXCHANGE AUTHORIZATION
17 I, ....., state that I am the person who completed the
18 Registration Identification; that I am of the age of .....
19 years; that I hereby authorize the Department of Public
20 Health to give to my (birth parent) (birth sibling)
21 (surrendered child) the following (please check the
22 information authorized for exchange):
23 [ ] 1. Only my name and last known address.
24 [ ] 2. A copy of my Illinois Adoption Registry
25 Application.
26 [ ] 3. A copy of the original certificate of live
27 birth.
28 I am fully aware that I can only be supplied with any
29 information about my (birth parent) (birth sibling)
30 (surrendered child) if such person has duly executed an
31 Information Exchange Authorization for such information which
32 has not been revoked; that I can be contacted by writing to:
33 ..... (own name or name of person to contact) (address)
34 (phone number).
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1 Dated (insert date).
2 ............ ..............
3 (witness) (signature)
4 (e) The form of the Denial of Information Exchange shall
5 be substantially as follows:
6 DENIAL OF INFORMATION EXCHANGE
7 I, ....., state that I am the person who completed the
8 Registration Identification; that I am of the age of .....
9 years; that I hereby instruct the Department of Public Health
10 not to give any identifying information about me to my (birth
11 parent) (birth sibling) (surrendered child); that I do not
12 wish to be contacted.
13 Dated (insert date).
14 ............. ...............
15 (witness) (signature)
16 (f) The Information Exchange Authorization and the
17 Denial of Information Exchange shall be acknowledged by the
18 birth parent, birth sibling, adopted or surrendered person,
19 adoptive parent, or legal guardian before a notary public, in
20 form substantially as follows:
21 State of ..............
22 County of .............
23 I, a Notary Public, in and for the said County, in the
24 State aforesaid, do hereby certify that ...............
25 personally known to me to be the same person whose name is
26 subscribed to the foregoing certificate of acknowledgement,
27 appeared before me in person and acknowledged that (he or
28 she) signed such certificate as (his or her) free and
29 voluntary act and that the statements in such certificate are
30 true.
31 Given under my hand and notarial seal on (insert date).
32 .........................
33 (signature)
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1 (g) When the execution of an Information Exchange
2 Authorization or a Denial of Information Exchange is
3 acknowledged before a representative of an agency, such
4 representative shall have his signature on said Certificate
5 acknowledged before a notary public, in form substantially as
6 follows:
7 State of..........
8 County of.........
9 I, a Notary Public, in and for the said County, in the
10 State aforesaid, do hereby certify that ..... personally
11 known to me to be the same person whose name is subscribed to
12 the foregoing certificate of acknowledgement, appeared before
13 me in person and acknowledged that (he or she) signed such
14 certificate as (his or her) free and voluntary act and that
15 the statements in such certificate are true.
16 Given under my hand and notarial seal on (insert date).
17 .......................
18 (signature)
19 (h) When an Illinois Adoption Registry Application,
20 Information Exchange Authorization or a Denial of Information
21 Exchange is executed in a foreign country, the execution of
22 such document shall be acknowledged or affirmed before an
23 officer of the United States consular services.
24 (i) If the person signing an Information Exchange
25 Authorization or a Denial of Information is in the military
26 service of the United States, the execution of such document
27 may be acknowledged before a commissioned officer and the
28 signature of such officer on such certificate shall be
29 verified or acknowledged before a notary public or by such
30 other procedure as is then in effect for such division or
31 branch of the armed forces.
32 (j) The Department shall modify these forms as necessary
33 to implement the provisions of this amendatory Act of 1999
34 including creating Registration Identification Forms for
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1 non-surrendered birth siblings, adoptive parents and legal
2 guardians.
3 (Source: P.A. 91-357, eff. 7-29-99; 91-417, eff. 1-1-00.)
4 Section 99. Effective date. This Act takes effect upon
5 becoming law.".