Access Request For Personal Information *** NOTE: This form should not be used for requests for information related to finalized adoptions. If you are requesting information related to finalized adoptions please download and complete the Request for Non-Identifying Information form and the Consent for Release of Non-Identifying Information. *** *** NOTE: If your request relates to a court proceeding do not use this form. Contact us for the appropriate form. *** Requester Information -- Name* First Last Full name appearing on records, if not the same as above:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home / Mobile Phone*Email Address* *Please Note: Security of email communication cannot be guaranteed. If you do not wish to communicate by email, please do not fill out this form. Instead, contact us in order to provide your request in writing using our paper form.Date of Birth Requester is requesting on behalf of:SelfSelf and Child(ren) - Names and Date of BirthChild(ren) - Names and Date of BirthOther - Explain, Name and Date of BirthChild(ren) or Other - Enter Name and Date of Birth, ExplanationIf requesting on behalf of someone else, specify authority:Substitute Decision-Maker -- (Explanation required)Executor of the Estate of a Deceased Person -- (Evidence required)Not ApplicableSubstitute Decision-Maker -- Explain (e.g., Custodial Parent, Access Parent, Guardian, Power of Attorney, etc.)*Please Note: You may be asked to provide supporting documentation.Please provide detail with regard to the information you require. For example, time frame or specific records that you are requesting:Have you requested access to these records in the past?NoYesIf Yes, when? Δ
