MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Request for Nonidentifying Information/Completed Adoption
SECTION I – REQUEST (PLEASE PRINT)
Date of Request	Indicate Below Type of Request
Biological Parents	Adult Siblings
Name of Requestor:	Last	First	M.I.
Address	City	State	Zip Code
Check the category you represent
Adult Adoptee	Adoptive Parent	Other )Please Specify)
To confirm my identity, I am supplying the following information: (Please check and provide a copy of one of the following, If legal guardian, a copy of the order of appointment must be submitted)
Birth Certificate	Marriage Certificate	Adoption Decree
Other (Please Specify)
To Assist the Children's Division in locating the record of the adoption, the following information is requested if known to the person making the request.
Adoption Completion	County	Date
Biological Parents (if known)	Father's Name Last	Middle	First
Mothers Name Last	Middle	First
Adoptive Parents	Parent #1's Name Last	Middle	First
Parent #2’s Name Last	Middle	First
Address at the time the adoption was completed:	Address Street	City	State	Zip
I solemnly certify that all of the above information provided in this request is true and accurate to the best of my knowledge.
Requestor Signature	Date
SECTION II – REQUEST (PLEASE PRINT)
County	Worker	Date
Check the box below which applies to the action required to locate the adoption record and responding to the request
Adoption known to this office and available information is supplied.
Adoption known to this office but records maintained in another Children's Division office.
Referred to:	Children's Division office. Available information regarding
the persons requested will be forwarded to the address listed above.
Adoption not known to the Children's Division office.

CONTINUE ON THE REVERSE SIDE

SECTION III – AVAILABLE NONIDENTIFYING INFORMATION IN DIVISION RECORDS
Biological Parents
Physical Description	Maternal Family	Paternal Family
Height	Weight	Height	Weight
Eyes	Hair	Skin	Eyes	Hair	Skin
Nationality
Religion
Medical History
Physical Description	Sibling 1	Sibling 2	Sibling 3	Sibling 4
Height	Weight	Height	Weight	Height	Weight	Height	Weight
Eyes	Hair	Skin	Eyes	Hair	Skin	Eyes	Hair	Skin	Eyes	Hair	Skin
Nationality
Religion
Medical History