Sample Letter for Adoptees to Obtain Non-Identifying Information
To Whom It May Concern:
My name is (your name). I was born on (your d.o.b) in (your town) (State). I was adopted at birth by (amoms name, nee, maiden), and (adads name) of (city, state aparents lived at adoption). My adoption was finalized in (your county) and was handled by (agency and/or attorney).
I want to request my full birth name and whether I was named by my birth mother or by a social worker or foster parent.
I understand I may only be entitled to "as much information concerning my natural parents as will not endanger the anonymity of the natural parents." I am therefore requesting copies of all original documents with identifying info whited out. If this request cannot be honored, I then request answers to the following:
Regarding my natural mother: 1. Age and Date of Birth 2. Name at time of my Birth 3. Height 4. Weight 5. Hair color 6. Eye color 7. Education 8. Religious background 9. Socio-Economic background 10. Ethnic origins (for example: mother Irish/English, father Italian/Italian) 11. Number and ages and sex of siblings that she had (cause of death if deceased) 12. Where she was born 13. Where she lived at the time of my Birth 14. Marital Status 15. Her usual occupation 16. Her Parents’ ages and ethnic backgrounds (for example: mother Irish/English, father Italian/Italian) 17. Her parents’ educational backgrounds 18. Her parents’ physical descriptions 19. Her parents’ usual occupation 20. If her parents were deceased, age & year they died and cause of death 21. Any and all other non-identifying information (hobbies, talents, interests,etc.)
Regarding my natural father: 1. Age and Date of Birth 2. Name at time of my Birth 3. Height 4. Weight 5. Hair Color 6. Eye color 7. Education 8. Religious Background 9. Socio-Economic Background 10. Ethnic Origins (for example: mother Irish/English, father Italian/Italian) 11. Number and ages and sex of siblings he had (cause of death if deceased) 12. Where he was born 13. Where he lived at the time of my birth 14. Marital Status 15. His usual occupation 16. His parents ages and ethnic origins (for example: mother Irish/English, father Italian/Italian) 17. His parents’ educational background 18. His parents’ physical descriptions 19. His parents’ usual occupations 20. If his parents were deceased, age & year they died and cause of death 21. Any and all other non-identifying information (hobbies, talents, interests,etc.)
I am hereby requesting complete medical histories on my natural mother, natural father, and their families.
I am requesting that you examine my file for the purpose of determining whether or not my natural mother and/or father placed on file, a consent form granting permission to disclose the information contained in my original birth certificate or any other identifying or non-identifying information pertaining to my natural mother and/or father.
Thank you for your help in this matter.
In addition to the standardized 'form' items, please include answers to the following additional requests. Please note that all items listed below, unless otherwise indicated, refer to both my birth mother and birth father: Full physical description of birth parents: a. color of eyes; b. color of hair; c. age at my birth; d. height; e. weight; f. complexion: g. any birthmarks, scars, tattoos? Nationality Religion(special denominations): Was I their first child? Any full siblings? Any half siblings? The first name of each birth parent: Where was each birth parent born? Did they reside in (insert city and state in which you, the Adoptee, were born) a. If answered "no", Were they from (put your state)? b. Were they from another state and came to _______ for my delivery and adoption? Which state were they each from? Birthdate of each birth parent: What was the occupation of each birth parent? What hobbies were known for each birth parent? What level of education was attained for each birth parent? In what county was my adoption finalized? Please list any/all childhood diseases or surgeries known for each birth parent: Please list any/all genetic disorders known for each birth parent: Please list any/all known diseases or illnesses experienced by each birth parent: a. were any of these diseases or illnesses experienced during my birthmother's pregnancy with me? b. were either birth parents exposed to German measles, polio or tuberculosis during the pregnancy? [Note: if you were born after the isolation of the AIDS virus, you may want to include that in this list. You may also want to form a question with regard to their use of alcohol and street drugs]. At the time of my adoption were my birth grandparents still living? a. If not, what did they die from? b. What were their names? At the time of my adoption were my birth great grandparents still living? a. If not, what did they die from? b. What were their names? Please include any medical records and/or information known for eachbirth parent. Please include any medical records, birth records, nursery log records of my birth and any known subsequent medical treatment prior to adoption: a. Name and address of the medical facility where treatment was administered: b. Name and address of my delivery doctor: c. Name and address of the attending pediatrician:
Thank you for your courtesy in providing me with the requested information.
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