MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION ADOPTION INFORMATION REGISTRY	Email to: CD.MOAdoptionInfoRegistry@dss.mo.gov Or RETURN TO: MISSOURI CHILDREN’S DIVISION ADOPTION INFORMATION REGISTRY P.O. BOX 88 JEFFERSON CITY, MISSOURI 65103
TO BE COMPLETED BY BIOLOGICAL PARENT WHO DESIRES CONTACT WITH ADOPTED CHILD
BIOLOGICAL PARENT REGISTRATION
SECTION A – REQUEST
PURSUANT TO THE AUTHORITY GRANTED IN 453.121 RSMo I, AM REQUESTING REGISTRATION OF MY DESIRE TO A FUTURE CONTACT WITH MY CHILD WHO WAS ADOPTED. I UNDERSTAND THAT I MAY CHANGE THIS INFORMATION AT A LATER DATE SHOULD MY LOCATION OR CIRCUMSTANCES CHANGE. PLEASE FILL OUT THE FORM COMPLETELY WITH ALL INFORMATION KNOWN TO YOU. PLEASE CHECK AND PROVIDE A COPY OF ONE OF THE FOLLOWING TO CONFIRM YOUR IDENTITY: BIRTH CERTIFICATE DRIVER’S LICENSE OR PHOTO ID
FATHER’S FULL NAME
LAST	FIRST	MIDDLE
DATE OF BIRTH	SOCIAL SECURITY NUMBER	RACE
White Black	Indian/Alaskan Asian/Pacific Islander
CURRENT ADDRESS (Street/City/State/Zip Code)	PHONE NUMBER
EMAIL
MOTHER’S FULL NAME AT TIME OF CHILD’S BIRTH
LAST	FIRST	MIDDLE
DATE OF BIRTH	SOCIAL SECURITY NUMBER	RACE
White Black	Indian/Alaskan Asian/Pacific Islander
MOTHER’S CURRENT FULL NAME
LAST	FIRST	MIDDLE
OTHER LAST NAMES USED
CURRENT ADDRESS (Street/City/State/Zip Code)	PHONE NUMBER
EMAIL
SECTION B – COMPLETE ALL KNOWN INFORMATION ON ADOPTED CHILD FOR WHICH CONTACT IS REQUESTED
FULL BIRTH NAME
LAST	FIRST	MIDDLE	RACE White Black Indian/Alaskan Asian/Pacific Islander	SEX M F
FULL ADOPTED NAME
LAST	FIRST	MIDDLE
DATE OF BIRTH	PLACE OF BIRTH	CITY	STATE	COUNTY
AGENCY/INDIVIDUAL THAT MADE PLACEMENT	COUNTY WHERE ADOPTION FINALIZED	DATE OF ADOPTION
ADDRESS
STREET	CITY	STATE	ZIP

ADOPTIVE PARENTS INFORMATION IF KNOWN
Adoptive Parent #1’s FULL NAME
LAST	FIRST	MIDDLE
Adoptive Parent #2’s FULL NAME
LAST	FIRST	MIDDLE
SECTION C – CERTIFICATION
I SOLEMNLY CERTIFY THAT ALL OF THE INFORMATION PROVIDED ON THIS REGISTRATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE	SIGNATURE OF REGISTRANT	DATE
SECTION D – TO BE COMPLETED BY CHILDREN’S DIVISION STAFF
REGISTRATION REQUEST FILED BY:	BIOLOGICAL PARENT	DATE
POSSIBLE MATCH LOCATED	DATE
NOTICE SENT TO LOCAL OFFICE FOR CONFIRMATION OF IDENTITY AND/OR NOTIFICATION OF OTHER PARTY TO MATCH IF IDENTITY CONFIRMED
YES NO	DATE
SECTION E – TO BE COMPLETED BY LOCAL OFFICE STAFF/PRIVATE AGENCY
DETERMINE STATUS OF BIOLOGICAL PARENT NOT REGISTERED WITH ADOPTION REGISTRY
UNKNOWN DECEASED	CANNOT BE LOCATED HAS NOW COMPLETED ADOPTION REGISTRY FORM (ATTACHED)	REFUSED TO REGISTER HAS FILED AFFIDAVIT WITH COURT CONFIRMED DATE
WORKER	DATE	ADDRESS
PRIVATE/COUNTY AGENCY