700-00127 – Disclosure of Identifying Information (04/2018) Page 1 of 1
STATEMENT OF
DISCLOSURE
OF
IDENTIFYING INFORMATION
I make the following statement regarding the release of information to the child named below:
(check one box only)
I consent to the release
to my child
of my identifying information
including my name and address,
should my child request that information after the age of 18 or emancipation.
I request that my name and address be kept confidential. I understand that a judge may decide to
release this information for very important reasons (including, but not limited to medical reasons)
even though I have requested confidentiality.
I understand that I may change my mind about the choice I have made at any time prior to the release of
identifying information by contacting the Adoption Registry, 103 South Main Street, Waterbury, VT 05671-
2401.
Information about Child:
Child's Full Name: ______________________________________________________________________
Date of Birth: _____________________________ Time of Birth: ____________________________
Place of Birth (town, state, country): _____________________________________________________________
My Information:
Full Name: ______________________________________________________________________
Date of Birth: _____________________________ Time of Birth: ____________________________
Place of Birth (town, state, country): _____________________________________________________________
Driver’s License #: _____________________________ Social Security #: _________________________
Mailing Address: ______________________________________________________________________
I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and
belief.
Signed and sworn to before me:
Date Signature of Notary Public Expiration Date
