Pennsylvania Adoption Information Registry Withdrawal of Authorization to Release Information (CY 984)
Pennsylvania Department of Human ServicesAdoptionForm CY 984Free downloadLast verified November 10, 2026
Withdraws an earlier authorization to release identifying information held by the Pennsylvania Adoption Information Registry. It goes to the registry at the Department of Human Services, not the vital records office.
Who can use this form
- An adoptee who is at least 18
- An adoptive parent of an adoptee who is under 18, incapacitated or deceased
- A birth parent
- A birth parent survivor
What to send with it
- Completed form, typed or printed in black or blue ink
- Your signature on the form
Where to send it
- Mail to
- Pennsylvania Adoption Information Registry P.O. Box 959 Camp Hill, PA 17001-0959
- State fee
- Not provided
- Typical processing
- Not provided
- Issued by
- Pennsylvania Department of Human Services
- Form revision
- 4/24
- Source
- Official government page