Search Services Request Form
All fields are required.
Date of Request:
02/07/2023
Requester:
Street Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
E-mail:
Date of Birth:
mm/dd/yyyy
Home Phone:
###-###-#### or (###) ###-####
Cell Phone:
###-###-#### or (###) ###-####
Preferred Method of Contact:
Home Phone
Cell Phone
Email
REFERRAL BY:
Birthparent
(adoptee aged 21 or older)
Adoptee
(18 years of age or over)
Adoptive Parent
(adoptee under age 18)
Legal Guardian of Adoptee
(adoptee under age 18)
Descendant of a deceased adoptee
Grandparent
(if birth parent consents, is incapacitated or deceased)
Birth sibling of an adoptee
(21 years or older)
(other legislation requirements specify authorized sibling requests)
Other
If 'Other', please specify:
SERVICES REQUESTED:
Education
(ACT 101, Search Service Options and Procedure information)
Search Information
Birthparent Requesting Update on Child
Update Information in File
Appointment for Adoptee to see Case Manager
Search & Reunion Services
Additional Comments:
FEES:
Non-identifying Search
$150.00
Identifying (Full Search Services)
$300.00
Reunion/ Miscellaneous Services
$49.00 per hour
casework counseling services