Government of Ontario: Ministry of Government Services

Office of the Registrar General

Adoption Information Disclosure Application to Register or Withdraw a Disclosure Veto

Please mail your completed form to the
Office of the Registrar General
PO Box 9000
Thunder Bay ON P7B 0A5
If you have any questions, please call
Within North America: 1 800 461-2156
In Toronto or Internationally: 416 325-8305

(THIS SPACE RESERVED FOR OFFICE USE ONLY)

Important
Please read through the instructions thoroughly before completing this form.
Please print clearly in blue or black ink.

Applicant’s Name:

Current Legal Surname (Last Name)
First and Middle Names

Mailing Address at which correspondence from this office regarding this application can be mailed to you:

Street No. Street Name
Apt. No. Buzzer No. PO Box
City/Town Province/State
Country Postal/Zip Code

* Telephone Number ( ) Ext.

* A telephone number may be used by this office to contact you regarding this application. If you do not wish to be contacted by
telephone, do not include a telephone number.

Service Requested: Check only one box.

Date of any previously submitted Disclosure Veto (if known)

Additional Information Included with this Disclosure Veto: Check all boxes that apply.

Do not complete if you are withdrawing a Disclosure Veto

Reasons for Disclosure Veto Medical History Family History

Please Identify if you are

The Adopted Person and you are (current age) years old (you must be at least 18 years old to apply) or

A Mother named on the original birth registration* or

A Father/other parent named on the original birth registration*

*See instructions for adoptive parents who are eligible.

Note: Complete the section below only if you are the adopted person.

Who should this Disclosure Veto or Withdrawal apply to? Check only one box

A mother named on the original birth registration or

A father/other parent, if named on the original birth registration or

Any parent named on the original birth registration

Information About Adopted Person AFTER Adoption

Legal Surname (Last Name) of Adopted Person
First Name Middle Name(s)

Sex Male Female

Date of Birth Year Month Day

Birth registration number (if known)

Date of adoption (if known) Year Month Day

Has the person named above ever had a legal name change? If “Yes” provide details below. Yes No

Previous Legal Surname (Last Name)
First Name Middle Name(s)

Place of Birth of Adopted Person Country Province/State
City/Town

Legal Surname of Adoptive Mother or Father (Last Name)
First Name Middle Name(s)
Any other Legal Surnames (Last Names)

Date of birth Year Month Day

Adoptive Mother’s or Father’s age (at time of this birth)

Place of Birth of Adoptive Mother or Father Country Province/State
City/Town

Legal Surname (Last Name) of Adoptive Father or Mother
First Name Middle Name(s)
Any other Legal Surnames (Last Names)

Date of birth Year Month Day

Adoptive Father’s or Mother’s age (at time of this birth)

Place of Birth of Adoptive Father or Mother Country Province/State
City/Town

Information About Adopted Person BEFORE the Adoption

Last Name
First Name Middle Name(s)

Sex Male Female

Date of Birth Year Month Day

Birth registration number (if known)

Place of Birth of Adopted Person Country Province/State
City/Town

Legal Surname (Last Name) of Mother or Father
First Name Middle Name(s)
Any other Legal Surnames (Last Names)

Date of birth Year Month Day

Mother’s or Father’s age (at time of this birth)

Place of Birth of Mother or Father Country Province/State
City/Town

Legal Surname (Last Name) of Father or Mother
First Name Middle Name(s)
Any other Legal Surnames (Last Names)

Date of birth Year Month Day

Father’s or Mother’s age (at time of this birth)

Place of Birth of Father or Mother Country Province/State
City/Town

Register a Disclosure Veto

(Subsection 48.5 (2) or (5) of the Vital Statistics Act)

(Do not complete this page if you only wish to Withdraw a Disclosure Veto and do not wish to
replace it with a new Disclosure Veto. Please proceed to page 6.)

Date:

I am the person shown as (Print Name - See Instruction Guide) on the adoption order or original birth registration and do not want my identifying information to be disclosed to:

Check only one box

The adopted person or
A mother named on the original birth registration or
A father/other parent, if named on the original birth registration or
Any parent named on the original birth registration

You may include with this Disclosure Veto a brief Statement that includes any or all of the following:

your medical history;
your family history;
your reasons for not wanting your identifying information to be disclosed

No other information should be provided on the Statement.

When the Disclosure Veto is in effect and a person who would otherwise be entitled applies for Post Adoption Birth Information, the person will be given a copy of this Statement if it is completed (please refer to instructions).

FOR OFFICE USE ONLY (DO NOT ENTER INFORMATION IN THIS SPACE)

Statement

(Subsection 48.5 (7) of the Vital Statistics Act)

This Statement is OPTIONAL.

The Statement applies if you are registering a Disclosure Veto. It does not apply if you are withdrawing a Disclosure Veto.

IMPORTANT INFORMATION

Do not include any information in this Statement that you don’t want disclosed.
The Statement will not be provided to a person if you withdraw the Disclosure Veto and the withdrawal is registered before disclosure happens.
The Statement will not be provided to a person if you submit a new Disclosure Veto and the new Veto is registered before disclosure happens. You can include a new Statement with a new Disclosure Veto.
The Statement will not be provided to a person if you later submit a Notice of No Contact or a Notice of Contact Preference and it is registered before disclosure happens.
If the Disclosure Veto ceases to be in effect because the person who submitted the Veto dies, the Statement will be disclosed unless you withdraw the Veto before your death.
The Statement and the “Notice to the recipient of this statement” that appears below the Statement will be provided to the person it is intended for, if he or she applies for and is entitled to your Post Adoption Birth Information.
Any Statement of medical history may be provided to a person who is a member of your birth family in the case of a severe medical illness.

Please use only the space provided below to provide any medical history.

Notice to the recipient of this statement:
The Statement above is provided by the person who registered a Disclosure Veto pursuant to subsections 48.5 (2) or 48.5 (5) of the Vital Statistics Act. The Office of the Registrar General is providing this Statement of Disclosure Veto to you as required by the Vital Statistics Act and the Office of the Registrar General assumes no liability for the truth or accuracy of the information provided in this statement.

Statement

(Subsection 48.5 (7) of the Vital Statistics Act)

Please use only the space provided below to provide any family history.

Please use only the space provided below to provide reasons for not wanting your identifying information to be disclosed.

Withdraw a Disclosure Veto

(Subsection 48.5 (11) of the Vital Statistics Act)

(Do not complete this page if you are Registering a Disclosure Veto. Please proceed to page 7.)

Date:

I am the person shown as (Print Name - See Instruction Guide) on the adoption order or original birth registration and withdraw the registered Disclosure Veto that is in effect and applies to:

Check only one box The adopted person or
A mother named on the original birth registration or
A father/other parent named on the original birth registration or
Any parent named on the original birth registration

FOR OFFICE USE ONLY (DO NOT ENTER INFORMATION IN THIS SPACE)

Application to Register or Withdraw a Disclosure Veto

As the applicant, you must sign and date this page in order for the application to be processed.

Making a false statement

On conviction, a person who willfully makes a false statement in this application is liable to a fine of not more than $50,000 or to imprisonment for a term of not more than two years less a day or both.

Signed Statement by the Applicant

I certify that the information given on this application form is true and correct to the best of my knowledge and belief.

I am aware that it is an offence to wilfully make a false statement on this form.

Signature of Applicant
Date of Signature

The information provided on this form is collected and may be used to determine your entitlement to and provide the service requested, search for and provide copies of the registered Statement or Withdrawal, and for adoption disclosure, severe medical searches, statistical and research purposes, in accordance with the Vital Statistics Act, R.S.O. 1990, c. V.4 and for law enforcement purposes.

You may direct enquires regarding collection of this information to: Supervisor, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge Street, Toronto ON M3M 3E6 or call 1 800 461-2156 in North America or 416 325-8305 in Toronto and Internationally.

IMPORTANT INFORMATION

Please read prior to submitting your application.

When a Disclosure Veto you file is registered, it replaces any Disclosure Veto, No Contact Notice or Notice of Contact Preference intended for the same person, that you previously filed and is currently in effect.
When a Disclosure Veto Withdrawal you file is registered, it causes the Disclosure Veto intended for the same person, which you previously filed and is currently in effect, to no longer be in effect.
For more information refer to the “Guide for Completing and Submitting an Application to Register or Withdraw a Disclosure Veto under the Vital Statistics Act”.