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Person Freed for Adoption But not Subsequently Adopted or Person Acting on his or Her Behalf

The following form can be used for Person Freed for Adoption But not Subsequently Adopted. The form can also be used by a person acting on his/her behalf.

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Application – Person Freed for Adoption but Not Subsequently Adopted  
or Person Acting on Adopted Per son’s Behalf 	
– VS210 C  
State File  Num	

ber	
_______________ 	
PERSONAL DATA  	
1.Name
2. Birthdate	3. Sex 4. Birthplace	
PARENTS  	
5a. Parent’s Name Prior to 1	st Marriage  5b. 
Other Parent’s Name Pr ior to 1st
 Ma rriage on Birth Certificate  	
COURT 
DATA  	
6a. Date Freed for Adoption  
6b. Name and Location of Court 	
APPLICANT 	
7. Name
8. Mailing Address
9.
Status (Check only one)	
  Person 18 years of age or older who was freed for adoption but not subsequently adopted.
 
  Legal custodian/guardian of person under 18 who was freed for adoption but not subsequently adopted.  
  Legal custodian/guardian of person determined by a court to be incapacitated and who  was freed for adoption but not 	
       subsequently adopted.      	
CONTACT 	
10. I wish contact with my biological parents.
11.
I wish contact with my biological full 
siblings who are 18	 years of age or older.	
12.I wish contact with my biological half-s
iblings who 	are 18 years of age or older.	
Yes 
Yes  
Yes  	No 
No  
No  	
13. If my biological parent or other parent has died, I wish contact with these relatives of that parent.	
Parent         Other Parent           Grandparent         Full Sibling               
Half Sibling              Aunt Uncle          Cousin 	
SPECIAL  INSTRUCTIONS:  	
CERTIFICATION  	
I hereby certify that I am the person named above, or the legal custodian or guardian of that person, and that I wish contact  
with the biological parents and/or other individuals indicated above.  
Signed:  ________

________________________________________________________   Date:  _______________________   S:\vr
adminf\AM aster forms\VS -210C.pdf R 04/2014  	
Check No.___________ Amount Paid ______________	 	
Maine Center for Disease Control and Prev	ention (Maine CDC)	 	220 Capitol Street   
11 State House Station        
Augusta, Maine 04333- 0011        
(207) 287- 3771       
Fax : (207) 287- 1093     TTY Users:  Dial 711 (Maine Relay) 
  Male
Female
Next: Publication Previous: Petition for Adoption
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