Date
Name of agency
Address of agency
City, state, zip

Subject: Request for nonidentifying information

On ______________________ I gave birth to a son/daughter at (name of hospital) in (name of city) and placed he/she for adoption through (name of agency or private attorney). The purpose of this letter is to request nonidentifying information on the placement of my son/daughter.

Please send me nonidentifying information on the adopting parents. I am interested in their ages, states of birth, states of residence at the time of placement, religion and occupation. Did they have or adopt other children, and if so, what are their ages and gender. How long were the parents married before adopting.

Has either my son/daughter or the adopting parents ever contacted the agency for updated information on me? ( ).

(If you have any medical problems mention them here).

Have they requested a Waiver of Confidentiality? I would like to request a Waiver of Confidentiality form so that I may have one put in my file.

Sincerely,
your name
address
city, state, zip code
telephone number

**must be notarized**