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State of __________________

County of ________________


I, _________________________________________________,
(adopted Person's Present Name)

being first duly sworn, say that my adoptive name is _____________________________________________,

(Adoptive Name)

born on ___________________________, in ____________________________ hereby request the Ohio Department of Health to provide me with a copy of the contents of my adoption file. Enclosed are copies of two items of identification. I am aware that other items of identification may be required before the copies can be mailed.



(Signature of Adopted Person)


(Street Address)


(City, State, Zip Code)

Sworn to before me and subscribed in my presence, this _____________ day of

_______________________, __________.
(Month), (Year)



(Signature of Notary)



(Date Commission Expires-Official Title)

Section 3107.38 of the Ohio Revised Code provides that an adopted person whose birth occurred in this state and whose adoption was decreed prior to January 1, 1964, may request in writing (notarized affidavit form) and two items of identification attached to the request, may receive copies of the contents of an adoption file. Items of identification include, but are not limited to, a motor vehicle operator's license or chauffeur's license, identification card, marriage record (to provide linkage between the maiden name and married name), social security card, credit card, military identification card or employee's identification card.

Effective October 25, 1996, the fee established for copies of the contents of an adoption file is $20.00 pursuant to Section 3705.241 of the Ohio Revised Code and should be made payable to: Treasury, State of Ohio. Requests should be mailed to Vital Statistics, P.O. Box 15098, Columbus, Ohio 43215-0098.

HEA 3011 (REV. 10/96)