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Fill and Sign the Bobbi W Y Lum Privacy Vs Secrety the Open Adoption Form

Fill and Sign the Bobbi W Y Lum Privacy Vs Secrety the Open Adoption Form

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THE STA TE O F NEW HA MPSHIRE JUDI CI AL BRA NCH Cour t Nam e: Ca se Na m e: Ca se Nu m ber: (if know n) INTERSTA TE A DOPTI ON PUTA TI VE FA THER REGI STRY I NFORM ATIO N 1. Peti tioner name( s) 2. Child’s birthpl ace (city/tow n and state) 3. Is ther e a putati ve f ather ’s registr y in the chi ld’s bi rth state? Y es No 4. If questi on #3 abov e i s answ ered y es, pl ease compl ete the f ollowing inform ati on and attach the appr opr iate f ees or other requirements i n or der for the cour t to pr ocess the sear ch r equest i n the other state: Registr y or ag ency name Mailing address Telephone number 5. If questi on #3 abov e i s answ ered no, pl ease l ist the steps y ou hav e taken to deter mi ne i f a registr y ex ists. Date Petitioner Signatur e Date Petitioner Signatur e State of , C ounty of This instr ument w as acknow ledg ed bef or e me on by My C ommi ssi on Ex pires Af fix Seal , if any Signatur e of Notar ial O fficer / T itle NHJB-2190-FP (10/01/2006) Page 1 of 1 (form erly AOC-082J-003)

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