Legal Forms, Documents and Contracts

Over 4550 free forms and legal documents. Find and download the one you need!

Department of Health and Human Services Record Release Authorization

In the case of wanting to adopt a child, the following form has to be completed and submitted.

Download

Extracted Text for Proper Search

NHJB-2171-FP (08/29/2014) Page 1 of 1 	
 
 	THE STATE OF NEW HAMPSHIRE	 	
JUDICIAL BRANCH 
http://www.courts.state.nh.us 	
 	
Court Name: 
Case Name: 
Case Number: 
  (if known) 	
   
  
  
DEPARTMENT OF HEALTH AND HUMAN SERVICES 
RECORD RELEASE AUTHORIZATION 	
(RSA 170-B:18, VI and 463:5, VI and 464-A:4, V) 
To:  Department of Health and Human Services and all its divisions 
I hereby authorize the release of any child or adult abuse and/or neglect record that you may find concerning 
me to the 	
(name of court)	   , 	
at 	(address of court)	        	
 1.  Name     
  Mailing address    
 2.  Also known by following names 	(example: maiden name)  	 	
   
   
   
   
 3.  Date of birth    
 4.  List other states where you have resided as an adult and when   
    
    
   
   
I understand that the information disclosed and provided by you under this 
request and release authorization is intended for use by the above named 
court, in conjunction with the above referenced matter and subject to any 
confidentiality requirements applicable to such legal proceeding. 
 
     
Date   Signature 	
State of     , County of      	
This instrument was acknowledged before me on        by            
         Date   Person Signing Above 
My Commission Expires      
Affix Seal, if any	          	Signature of Notarial Officer / Title	 	
The court requires that the search be conducted and  the information be provided as specified above.   
PER ORDER OF THE COURT, 
     
Date  Clerk of Court 	
Official Use Only
Next: Dept of Health and Human Services or Agency Surrender of Parental Rights Previous: Dismissal of Adoption
If you want to remove Department of Health and Human Services Record Release Authorization from this website please contact us providing the reasons together with this url: https://formsarchive.com/department-of-health-and-human-services-record-release-authorization/

Leave a Reply

Your email address will not be published. Required fields are marked *

You can use these HTML tags and attributes <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>