New York Adoption Information Registry Birth Parent Registration Form (Release of Name and Address) (DOH-4455)

Who can use this form

• Birth parents who consent to an adoption or sign an instrument of surrender. If both do, each completes their own form.
• A birth parent may also use it any time after the adoption to agree to release, withdraw agreement or update contact information.
• Do not complete it for children born or adopted outside New York State.
• The birth parent signs under penalty of perjury before a notary public.

What to send with it

• The completed form with Yes or No checked in item 4. If neither is checked, the answer is treated as No unless a completed form is already on file.
• At the time of the adoption: the form goes to the agency or attorney handling the adoption, who files it with the court. The court sends it to the Adoption Registry.
• After the adoption: a new notarized form mailed to the Adoption Information Registry to change your answer or your contact information.
• Medical information updates on the medical care provider's letterhead, with the provider's name, address, telephone number and signature.

Where to send it

Mail to

New York State Department of Health Adoption Information Registry P.O. Box 2602 Albany, NY 12220-2602

State fee

Not provided

Typical processing

Not provided

Form revision

10/2008

Source

Official government page