Free Adoption Information Sheet - Hawaii

STATE OF HAWAII FAMILY COURT FIRST CIRCUIT

ADOPTION INFORMATION SHEET

CASE NUMBER FC-A NO.

Instructions: The Attorney, Petitioner(s) Pro Se or the Agency completes this form. In "closed" or confidential adoptions, this page should not be revealed to the Petitioners when completed. After the adoption has been completed, a copy of this form will be submitted to the Adoption Records Unit for use upon receipt of disclosure requests (See HRS Section 578-15).

Child(ren)'s last name at birth:

Child(ren)'s First & Middle Names 1. 2. 3. 4. Adoption Agency (if any): ADOPTIVE PARENTS
Full Legal Name (include birth/maiden names) Address Telephone Birth Date Social Security Number Ethnic Background NATURAL PARENTS Name Address Telephone Birth Date Social Security Number Ethnic Background Legal Only Father
(Full Name and Address)

Child(ren)'s Full Name After Adoption

Adoptive Father

Adoptive Mother

Father [ ]Natural [ ]Legal [ ]Adjudicated

Mother

The undersigned declares under penalty of perjury that the above information is true and correct. Signature: [ ]Attorney [ ]Petitioner Pro Se [ ]Agency Representative

08/07/01

ADOPTION INFORMATION SHEET