Free PC-607 - Connecticut

PETITION/AUTHORIZATION FOR RELEASE OF ORIGINAL BIRTH CERTIFICATE PC-607 REV. 12/02

STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. ]

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF [Name, address, zip code, and telephone number.]

DISTRICT NO. ORIGINAL BIRTH NAME DATE OF BIRTH OF ADOPTED PERSON

Hereinafter referred to as the petitioner or the adopted person. BIRTH MOTHER'S FIRST NAME AND MAIDEN NAME

PLACE OF BIRTH[ Town/City]

FATHER'S NAME

TOWN/CITY WHERE BIRTH IS RECORDED

THE PETITIONER REPRESENTS that he or she is the adopted person named above and is now an adult "adopted person" as defined in C.G.S. §45a-743. THE PETITIONER FURTHER REPRESENTS that he or she was born in the town/city above written and that his or her birth records are recorded in the Bureau of Vital Statistics of the town/city above written. THE PETITIONER FURTHER REPRESENTS that he or she is seeking the authorization of the probate court for the release of the original birth certificate. WHEREFORE, THE PETITIONER REQUESTS that, pursuant to the provisions of C.G.S. 7-53, the Court order the disclosure of the information herein sought by the Bureau of Vital Records of the above-named town/city or the State Department of Public Health, Bureau of Vital Records.

The representations contained herein are made under the penalties of false statement.

Date:

...................................................................................... Petitioner:

IDENTIFICATION FURNISHED: [Attach a copy of your driver's license. If you do not have a driver's license, attach a copy of another official form of photo identification, such as a DMV Connecticut Identification Card or passport.] Driver's License No. Birth Certificate Issued By Other Identification State of

PETITION/AUTHORIZATION FOR RELEASE OF ORIGINAL BIRTH CERTIFICATE PC-607

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