Application for adoption information: Relative or guardian of adopted person who is deceased or does not have capacity

Transcription

1 The purpose of the application for adoption information: is deceased or does not have capacity form This form is for use by a relative or guardian of an adult adopted person to apply for adoption information on his or her behalf where the adult adopted person to apply for adoption information or by a relative where the adopted person is deceased. If an adopted person is deceased, or does not have capacity to make the application, his or her parent, spouse, sibling or child may apply for the information on his or her behalf. An adopted person s guardian may also apply if the person does not have capacity to apply. A parent, spouse, sibling or child of an adopted person or a birth parent, applying on their behalf, may be provided with the following adoption information: the adopted person s name before the adoption prescribed documents relating to the adoption, including a copy of the adoption order the adopted person s birth parent/s name at the time of the adoption the adopted person s birth parent/s date of birth the name and date of birth of any other adopted person who is an adult who has at least one birth parent in common with the adopted person (pre-adoption sibling). If the adopted person, birth parent and/or any pre-adoption sibling have provided written consent a relative or guardian may also be provided with his or her current name and address as provided to Adoption Services. If the birth parent or sibling who was also adopted has a contact statement in place requesting no contact, the relative or guardian will be notified of the contents of the contact statement and any explanation given by the birth parent or sibling (who was adopted) before receiving the adoption information. If the adoption took place before 1 June 1991, before receiving the requested information, you will be required to have an interview either face to face, or by telephone, with Adoption Services to receive advice about the person s wish not to be contacted. In addition, you will be asked to sign an acknowledgement that you have been informed of the person s wish not to be contacted, and that you understand that contacting him or her is an offence under section 272 of the Adoption Act A relative or guardian may also be provided further information, and offered support, to assist him or her to understand the reasons why the person does not wish to be contacted, or in relation to any other relevant issues. You are required to attach the following documents to this form to establish that you are eligible to apply on behalf of adopted person: a certified copy of documents that provide evidence of the adopted person s lack of capacity to apply for information a certified copy of documents that provide proof of your relationship to the adopted person a certified copy of documents that provide evidence that the adopted person is deceased (if applicable). Proof of identity You are required to provide the original or a certified copy of two documents to prove your identity, for example: A driver licence, passport, birth certificate, pension card, credit card, Medicare card or student card. In addition, if you have previously been known as another name, you are required to provide the original or a certified copy of proof of change of name such as a marriage certificate or deed poll, in addition to the two forms of identification as mentioned above. If you have produced the original of the two documents for inspection and copying by a departmental officer you do not need to attach a certified copy of the proof of identity documents to this form. The full list of identification documents that may be accepted is available on the Queensland Government website An appropriate person to witness your signature must be present when you sign this form. The witness cannot be a relative. An appropriate witness includes: An officer of the Department of Communities, Child Safety and Disability Services A lawyer or notary public A Justice of the Peace or Commissioner for Declarations A Police Officer A medical practitioner Information to assist you to locate a Justice of the Peace is available at: Tick all boxes where required and print clearly using BLOCK LETTERS. Attach additional pages if you wish to provide further information. Form 14 Version 5 Page 1 of 6

2 Please return completed form: by mail to: by courier or in person to: Assistance in completing this form is available from: Adoption Services Department of Communities, Child Safety and Disability Services GPO Box 806 Brisbane QLD 4001 Adoption Services Department of Communities, Child Safety and Disability Services Level 1, 111 George Street Brisbane QLD 4000 Adoption Services Telephone: or (free call within Queensland) Post Adoption Support Queensland Telephone: Part A Applicant - Adult relative or guardian to complete Preferred title (for example, Mr, Mrs, Ms, Dr) Current surname Current given name/s Date of birth Gender Male Female ACR number (if known) Residential address Number and street address Suburb State/Territory Postcode Postal address as above Number and street address / PO Box Suburb State/Territory Postcode Telephone numbers - please indicate with an * which phone number is your preferred contact number. Home: Mobile: Work: Please indicate if you do not wish to be contacted by telephone Yes No Form 14 Version 5 Page 2 of 6

3 address (if applicable) Are you of Aboriginal or Torres Strait Islander descent? Yes, Aboriginal descent Yes, Aboriginal and Torres Strait Islander descent Yes, Torres Strait Islander descent No Unknown Your relationship to adopted person (please tick) Spouse Parent Sibling Child Please attach certified copies of documents that provide proof of your relationship with the adopted person Applicant s birth certificate Applicant s marriage certificate (to prove marriage or name change) Certified copy of deed certificate if your name has changed by deed poll Details of your relative s inability to apply for information A relative of an adopted person may apply for adoption information if the adopted person has died or does not have the capacity to apply for the information. Is the adopted person deceased? No Yes If yes, please attach a certified copy of documents that provide evidence that the birth parent is deceased and go to Part B. Does the adopted person have capacity to apply for information (if applicable)? Yes No If no, please attach documentary evidence confirming the adopted person does not have capacity to apply for information. Certified copy of declaration of incapacity Certified copy of guardianship order Letter from treating medical specialist confirming the adopted person s lack of capacity to apply on their own behalf. Part B Details of your adopted relative on whose behalf you are applying for information Please enter as much information as is known. Current surname Current given name/s Name at the time of the adoption Date of birth Place of birth (if known) Date of death (if applicable) / / Certified copy of death certificate of adopted person attached Form 14 Version 5 Page 3 of 6

4 Gender Residential address (or at the time of death where applicable) Male Female ACR number (if known) Number and street address Suburb State/Territory Postcode Adoptive mother Adoptive father Full name (at time of the adoption) (if known) Date of birth Part C Release of information (completion of this section is optional) Complete this section if you want to consent to your relative s current name and address being given to a person who applies for information Although you are completing this form to apply for pre-adoption information on behalf of your adopted relative, you may wish to take this opportunity to provide consent to release your relative s current name and address (as provided on this form if applicable) if an application is made about him or her to Adoption Services. If a birth parent (or a relative or guardian of the birth parent where relevant) or a sibling who was also adopted, applies to Adoption Services for information about an adopted person, he or she may be given his or her name as it was at the time of the adoption, date of birth and prescribed documents relating to the adoption. If you provide written consent, Adoption Services may also give a person who applies for information about an adopted person to whom you are related, his or her current name (if his or her name has changed), or name at the time of his or her death (if applicable) and address provided on this form (if applicable). Consent to the release of current name and address information - please tick to indicate: Yes I consent to a person who applies for information about my adopted relative being given his or her current name and current address (or address at the time of death where applicable). No I do not consent to my adopted relative s name and current address (or at the time of death where applicable) being given to a person who applies for information about him or her. Complete this section to indicate whether you agree to your current name and address being given to a person who applies for information about your relative If you provide written consent, Adoption Services may also give a person who applies for information about an adopted person to whom you are related, your name and address. Please complete the section below if you want your name and address to be given to a person who applies for information about your relative: Yes I consent to my current name and address being given to a person who applies for information about my relative Form 14 Version 5 Page 4 of 6

5 No I do not consent to my name and current address being given to a person who applies for information about my relative Complete this section to indicate whether you agree to your relative s current name and address being given to a pre-adoption sibling A pre-adoption sibling is a person who would have been the brother or sister of an adopted person if the adoption had not happened and he or she is not also an adopted person. If the adopted person has a pre-adoption sibling who makes an application for information about the adopted person, he or she may be provided with the adopted person s current name and address (if applicable) with your written consent. Please complete this section below if you want the adopted person s current name and address to be provided to a pre-adoption sibling who applies for information. Yes, I consent to the following adoption information being given to the adopted person s pre-adoption sibling No, I do not consent to any information about my relative being given to his or her pre-adoption sibling Yes, I consent to my relative s pre-adoption sibling being given my relative s name as it was at the time of the adoption, his or her date of birth and prescribed documents relating to the adoption, (including a copy of the adoption order) if a pre-adopted sibling applies for information AND (optional) I also consent to my relative s pre-adoption sibling being given my relative s current name and address if he or she applies for information. Part D - Proof of identity and (adult relative s) declaration I have provided an original or certified copy of two identification documents and these documents have been sighted by a departmental officer (please tick) Yes No I have attached a certified copy of two proof of identification documents to this application. Identification Document 1 Identification Document 2 Form 14 Version 5 Page 5 of 6

6 I, hereby make (insert full name) application for adoption information and declare that all the information provided in this application is true and correct to the best of my knowledge. MUST BE SIGNED AND DATED IN THE PRESENCE OF THE WITNESS Applicant s signature Date Place (city/town) Note: If is an offence under the Adoption Act 2009 for any person to knowingly provide false or misleading information Certificate of witness Witness s full name Qualification Departmental officer Justice of the Peace Lawyer Commissioner for declarations Police officer Doctor Registered number (if known) Phone number Address The applicant showed me two documents that provide proof of his or her identity. This application form was signed by the applicant in my presence on Date / / at place (insert State) Witness s signature Privacy Notice The Adoption Act 2009 authorises the Department of Communities, Child Safety and Disability Services to collect the information on this form for the purposes of assessing your application for pre-adoption information, and where applicable, the provision of the relevant identifying and non-identifying information. The Department of Communities, Child Safety and Disability Services may provide some or all of this information to the Registrar, Births, Deaths and Marriages and/or to a relevant tribunal or court or person as authorised under the Act. All information obtained in the process of assessing your application for pre-adoption information, and where applicable, the provision of the relevant identifying and non-identifying information will be managed in accordance with the Information Privacy Principles described in the Information Privacy Act Form 14 Version 5 Page 6 of 6