New Jersey Department of Health

Vital Statistics and Registry

PO Box 370

Trenton, NJ 08625-0370	NEW RECORDS SYSTEM FOR BIRTH PARENTS

CONTACT PREFERENCE	A
A birth parent of an adopted person may submit a Contact Preference document to the State Registrar indicating his or her preference regarding contact with the adopted individual. The birth parent may change his or her preference at any time by submitting a revised Contact Preference document to the State Registrar.

We need the following information in order to find and match your request with our existing files. If you fail to provide complete and accurate information, then we may be unable to accept and process your request.

NOTE: You must also complete and submit a Family History Information form, which includes medical, cultural and social history information, in order for your Contact Preference form to be accepted for filing.
ORIGINAL BIRTH CERTIFICATE INFORMATION
Please provide complete and accurate information. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.
CHILD’S INFORMATION
Child’s FIRST Name on Child’s Original Birth Certificate:
Child’s MIDDLE Name on Child’s Original Birth Certificate:
Child’s LAST Name on Child’s Original Birth Certificate:
Suffix:
Note: If you are unsure of the exact date of the child's birth, please enter your best estimate.
Child’s Date of Birth:	__ __ / __ __ / __ __ __ __	Actual Estimate
Sex:	Male Female
Country of Birth:
State of Birth:
County of Birth:
Municipality of Birth:
MOTHER’S INFORMATION
Mother’s FIRST Name on Child’s Original Birth Certificate:
Mother’s MIDDLE Name on Child’s Original Birth Certificate:
Mother’s LAST Name on Child’s Original Birth Certificate:
Mother’s Date of Birth:	__ __ / __ __ / __ __ __ __
FATHER’S INFORMATION
Father’s FIRST Name on Child’s Original Birth Certificate:
Father’s MIDDLE Name on Child’s Original Birth Certificate:
Father’s LAST Name on Child’s Original Birth Certificate:
Father’s Date of Birth:	__ __ / __ __ / __ __ __ __
BIRTH PARENT INFORMATION
NOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if you wish to retain your privacy at this time.
Birth Parent’s Current First Name:
Birth Parent’s Current Middle Name:
Birth Parent’s Current Last Name:
Birth Parent’s Date of Birth:	__ __ / __ __ / __ __ __ __
Birth Parent’s Relationship to Child: Mother Father
Phone 1:	Home Mobile Work
Phone 2:	Home Mobile Work
Phone 3:	Home Mobile Work
Email Address:
Mailing Address:
City:	State:	Zip:
The Contact Preference form is only an expression of the birth parent's wishes regarding contact with the adoptee. There is no law requiring the adoptee to follow the preference selected by the birth parent on the form.
BIRTH PARENT’S CONTACT PREFERENCE
State your preference about contact with the adopted child.

Note: Selection is required.
A.	I would like to be contacted directly.

I have provided the required contact preference information and an updated Family History Information document and am submitting them to the State Registrar as set forth in this document. (Complete required information on the previous page.)
B.	I would prefer to be contacted only through an intermediary.

I have provided the required contact preference information and an updated Family History Information document. I am submitting both to the State Registrar as set forth in this document. I have named the listed individual to act as an intermediary. (Complete the following required information.)
Name of Individual or Agency:
Mailing Address:
City:	State:	Zip:
Phone 1:	Home Mobile Work
Phone 2:	Home Mobile Work
Phone 3:	Home Mobile Work
Email Address:
C.	I would prefer to not be contacted at this time.

If I decide later that I would like to be contacted, I will submit a revised Contact Preference form to the State Registrar. While I do not wish to be contacted at this time, I have completed the Family History Information form and am submitting it to the State Registrar. Additionally, I understand that because I have indicated a no contact preference I must update the Family History Information form and submit it to the State Registrar every ten (10) years until I reach the age of forty (40) and every five (5) years thereafter.
By signing, I certify that I am the birth parent of the adoptee and, that, to the best of my knowledge, the information I am supplying is correct and accurate. I understand that if I falsely represent that I am the birth parent of the adoptee on this form, then I may be subject to penalties pursuant to N.J.S.A. 26:8-69.
Signature of Birth Parent:
Date:

REG-36A	For questions or additional Information:

AUG 15	www.nj.gov/health/vital ( 866-649-8726, EXT. 582	Page 3 of 3.

New Jersey Department of Health

ewhite

2015-06-10

NJDOH