Government of Ontario

Application to Request Non-Identifying Information Relating to an Adoption

(THIS SPACE RESERVED FOR OFFICE USE ONLY)

BRI _____________ CID _____________

If you have any questions, please contact:
ServiceOntario
Toll-free: 1 800 461-2156 or
Toronto: 416 325-8305

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

PART A: Applicant Information

Applicant Name

Mr. Mrs. Ms. Miss.

Surname (Last Name)

First Name

Middle Name(s)

Maiden Name or Other Surname(s) (if applicable)

Sex

Male Female

Date of Birth (dd/mm/yyyy)

Mailing Address

Street No.

Street Name

Apt. No.

Buzzer No.

PO Box

City/Town

Province/State

Country

Postal/Zip Code

Daytime Telephone Number

Enter area code Enter telephone number Ext.

Can a message be left for you at this number?

Yes No

Alternate Telephone Number

Enter area code Enter telephone number Ext.

Additional Information About the Applicant

Please identify if you are (check only one box)

An adopted person 18 years of age or older
An adopted person under 18 years of age with the consent of your adoptive parent
An adoptive parent

A birth parent of an adopted person (please check the appropriate box)

Birth Mother
Birth Father

A birth grandparent (please check the appropriate box)

Maternal grandmother
Maternal grandfather
Paternal grandmother
Paternal grandfather

A birth sibling of an adopted person and you are 18 years of age or older
A child of a deceased adopted person and you are 18 years of age or older
A sibling of a birth parent, and you are 18 years of age or older
An adopted person 18 years of age or older, applying to receive Non-identifying information regarding a birth sibling who is also adopted.

PART B: Information About the Adopted Person AFTER Adoption

Adoptive Surname (Last Name) of Adopted Person

First Name

Middle Name(s)

Sex

Male Female

Date of Birth (dd/mm/yyyy)

Date of Adoption (if known)

Has the person named above had a legal name change after adoption?

Yes No

If "Yes" provide details below

Current Legal Surname (Last Name)

First Name

Middle Name(s)

Place of Birth of Adopted Person

City/Town

Province/State

Country

Adoptive Parent "A"

Legal Surname (Last Name) of Adoptive Parent "A" (at time of adoption)

First Name

Middle Name(s)

Any Other Legal Surnames (Last Name)

Adoptive Parent "B"

Legal Surname (Last Name) of Adoptive Parent "B" (at time of adoption)

First Name

Middle Name(s)

Any Other Legal Surnames (Last Name)

PART C: Information About the Adopted Person PRIOR to Adoption

Adopted Person

Surname (Last Name) of Adopted Person (at time of birth)

First Name

Middle Name(s)

Sex

Male Female

Date of Birth (dd/mm/yyyy)

Birth Registration Number (if known)

Place of Birth of Adopted Person

City/Town

Province/State

Country

Birth Mother

Legal Surname (Last Name) of Birth Mother (at time of birth)

First Name

Middle Name(s)

Any Other Legal Surnames (Last Name)

Date of Birth (dd/mm/yyyy)

Birth Mother's Age (at time of this birth)

Place of Birth

City/Town

Province/State

Country

Birth Father

Legal Surname (Last Name) of Birth Father (at time of birth)

First Name

Middle Name(s)

Any Other Legal Surnames (Last Name)

Date of Birth (dd/mm/yyyy)

Birth Father's Age (at time of this birth)

Place of Birth

City/Town

Province/State

Country

PART D: Adoptive Parent Consent Form

If you are an adopted person under 18 years of age, this section must be signed by your adoptive parent.

I, (Name of Adoptive Parent) hereby confirm that I am the adoptive parent of (Name of Adopted Person) and provide my consent for their application for Non-identifying Information under section 11 of O.Reg. 464/07 made under the Child and Family Services Act.

(Signature of Adoptive Parent)

(Date of Signature)

PART E: Signed Statement by the Applicant

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

(Signature of Applicant)

(Date of Signature)

Mail your completed application to:

Custodian of Adoption Information
P.O. Box 654
77 Wellesley St. West
Toronto ON M7A 1N3

The information provided on this form is collected and will be used to determine your entitlement to receive Non-identifying Information relating to an adoption under section 11 of O.Reg. 464/07 made under the Child and Family Services Act. If you have any questions about the collection of information please contact: Director, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge St, Toronto ON M3M 3E6 or call 1 800 461-2156 / 416 325-8305.

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