Sample Letters
Consent to Release of Identifying Information


Note: Your letter must be notarized. It should be typed in a formal fashion, and sent certified mail - return receipt requested. Keep the receipt in your correspondence file attached to a copy of this letter. You may wish to have an attorney review this, as it is a legal document.
Make certain to provide a copy to each of the following: the court of finalization; the Dept. of Economic Security Division of Children, Youth and Families (DCYF); the adoption agency or private attorney used.

Adoptee's Consent to Release of Identifying Information

Date:


Entity
Address
City, State, Zip

TO ALL CONCERNED PARTIES:

      Pursuant to Arizona Revised Statute Title 8 -121(E), I hereby formally request that this letter and/or copies hereof be immediately placed in all records and files pertaining to my adoption as follows:

            - (give full adopted name)
            - (give date, time, and place of adoption and relinquishment if known)

      This is to be considered my legal consent to release of identifying information. It serves as my legal authorization to waive the confidentiality guaranteed to me by any laws and/or organizations of the state of Arizona; and includes all court records, agency records, hospital records, and anything considered to be identifying information.

      The effects of this consent and waiver are to extend only to my birth parents, birth siblings, any other blood relatives, and/or their legal representatives. The following information may hereby be released in full to the above mentioned parties:

            - My full name (present and maiden)
            - My current address (give address)
            - My current telephone number (if desired)

      This consent gives my full and legal permission to release my present identity; with the exclusion of any reference to my adoptive parents, and/or adoptive relatives. Please respond to this request. Should you refuse it, denote the state law that supports such an action. This letter is to remain in full effect until otherwise revoked by myself in writing.

Sincerely,



(your signature)
Address
City, State, Zip


Adoptive Parent's
Consent to Release of Identifying Information

Date:


Entity
Address
City, State, Zip

TO ALL CONCERNED PARTIES:

      Pursuant to Arizona Revised Statute Title 8 -121(E), we hereby formally request that this letter and/or copies hereof be immediately placed in all records and files pertaining to the child we legally adopted as shown below:

            - (give child's full adopted name)
            - (give date, time, and place of birth and relinquishment)

      This is to be considered our legal consent to release of identifying information. It serves as our legal authorization to waive the confidentiality guaranteed to ourselves and our adopted child by any laws and/or organizations of the state of Arizona; and includes all court records, agency records, hospital records, and anything considered to be identifying information.

      The effects of this consent and waiver are to extend only to our adopted child's birth relatives and/or their legal representatives. The following information may hereby be released in full to the above mentioned parties:

            - Our full names (present and maiden)
            - Our current address (give address)
            - Our current telephone number (if desired)

      This consent and waiver gives our full and legal permission to release our present identity as described above. Please respond to this request. Should you refuse it, denote the state law that supports such an action. This letter is to remain in full effect until otherwise revoked by us both in writing.

Sincerely,



(Both adoptive parent's signatures)
Address
City, State, Zip


Birth Parent's
Consent to Release of Identifying Information

Date:


Entity
Address
City, State, Zip

TO ALL CONCERNED PARTIES:

      Pursuant to Arizona Revised Statute Title 8 -121(E), I hereby formally request that this letter and/or copies hereof be immediately placed in all records and files pertaining to my child which was surrendered for adoption as follows:

            - (give full birth name of child)
            - (give date, time, and place of birth and relinquishment)
            - (give your full name at the time of birth and relinquishment)

      This is to be considered my legal consent to release of identifying information. It serves as my legal authorization to waive the confidentiality guaranteed to me by any laws and/or organizations of the state of Arizona; and includes all court records, agency records, hospital records, and anything considered to be identifying information.

      The effects of this consent and waiver are to extend only to my relinquished child, and any of their adoptive relatives or legal representatives. The following information may hereby be released in full to the above mentioned parties:

            - My full name (present and maiden)
            - My current address (give address)
            - My current telephone number (if desired)
            - All medical records in your files; including those enclosed with this consent and waiver.

      This consent and waiver gives my full and legal permission to release my present identity as described above. Please respond to this request. Should you refuse it, denote the state law that supports such an action. This letter is to remain in full effect until otherwise revoked by myself in writing.

Sincerely,



(your signature)
Address
City, State, Zip

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