Government of Ontario: Ministry of Government Services

Office of the Registrar General

Adoption Information Disclosure Application to Register or Withdraw a Notice of Contact Preference

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 Notice of Contact Preference (if known)

Additional Information Included with this Notice of Contact Preference:

Do not complete if you are withdrawing a Notice of Contact Preference

The methods in which I would like to be contacted

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 Notice of Contact Preference or Withdrawal apply to? Check only one box

A mother named on the original birth registration or

A father/other 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 (Last Name) of Adoptive Mother or Father
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 Notice of Contact Preference

(Subsection 48.3 (1) or (2) of the Vital Statistics Act)

(Do not complete this page if you only wish to Withdraw a Notice of Contact Preference and
do not wish to replace it with a new Notice of Contact Preference. Please proceed to page 5.)

Date:

I am the person shown as (Print Name - See Instruction Guide) on the adoption order or original birth registration and wish to be contacted by:

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

You may include with this Notice of Contact Preference a brief statement about how you would like to be contacted.

For example:

telephone - provide a telephone number or numbers
e-mail - provide an e-mail address
letters/information - provide your current name and a mailing address
meet in person – provide details of how you would like to meet
intermediary or third party – provide details

Only information stating how you would like to be contacted should be provided on the statement.

When the Notice of Contact Preference is in effect and a person who is entitled applies for Post Adoption Birth Information, the person will be given a copy of this statement, if it is completed, in addition to the Notice (please refer to instructions).

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

Statement

This Statement is MANDATORY.

The statement applies if you are registering a Notice of Contact Preference. It does not apply if you are withdrawing a Notice of Contact Preference.

IMPORTANT INFORMATION:

Only information stating how you would like to be contacted should be provided in this statement.
Do not include any information in this statement that you don’t want disclosed.
The Notice and any statement will not be provided to a person if you withdraw the Notice of Contact Preference and the withdrawal is registered before disclosure happens.
The Notice and any statement will not be provided to a person if you submit a new Notice of Contact Preference and the new Notice is registered before disclosure happens. You must include a new statement with a new Notice of Contact Preference.
The Notice and any statement will not be provided to a person if you later submit a Disclosure Veto or a No Contact Notice and it is registered before disclosure happens.
The Notice and any statement including the “Notice to the recipient of the 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 contact information contained in your statement may be used to contact you in the case of a severe medical illness of a member of your birth family.

Please use only the space provided below to provide your contact information and preference(s).

Notice to the recipient of this statement:
The statement above is provided by the person who registered a Notice of Contact Preference pursuant to subsections 48.3 (1) and 48.3 (2) of the Vital Statistics Act. The Office of the Registrar General is providing this Notice of Contact Preference and any statement 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.

Withdraw a Notice of Contract Preference

(Subsection 48.3 (6) of the Vital Statistics Act)

(Do not complete this page if you are Registering a Notice of Contact Preference. 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 Notice of Contact Preference 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

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

Application to Register or Withdraw a Notice of Contact Preference

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 (Above)
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 Notice of Contact Preference you file is registered, it replaces any Notice of Contact Preference, Disclosure Veto or No Contact Notice intended for the same person, that you previously filed and is currently in effect.
When a Notice of Contact Preference Withdrawal you file is registered, it causes the Notice of Contact Preference 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 Notice of Contact Preference under the Vital Statistics Act”.