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
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