Ohio Revised Code
Chapter 3107 | Adoption
Section 3107.083 | Contents of Form Signed by Parent.

Effective: March 20, 2015
Latest Legislation: Senate Bill 23 - 130th General Assembly
The director of job and family services shall do all of the following:
(A)(1) For a parent of a child who, if adopted, will be an adopted person as defined in section 3107.45 of the Revised Code, prescribe a form that has the following six components:
(a) A component the parent signs under section 3107.071, 3107.081, or 5103.151 of the Revised Code to indicate the requirements of section 3107.082 or 5103.152 of the Revised Code have been met. The component shall be as follows:
"Statement Concerning Ohio Law and Adoption Materials
By signing this component of this form, I acknowledge that it has been explained to me, and I understand, that, if I check the space on the next component of this form that indicates that I authorize the release, the adoption file maintained by the Ohio Department of Health, which contains identifying information about me at the time of my child's birth, will be released, on request, to the adoptive parent when the adoptee is at least age eighteen but younger than age twenty-one and to the adoptee when he or she is age twenty-one or older. It has also been explained to me, and I understand, that I may prohibit the release of identifying information about me contained in the adoption file by checking the space on the next component of this form that indicates that I do not authorize the release of the identifying information. It has additionally been explained to me, and I understand, that I may change my mind regarding the decision I make on the next component of this form at any time and as many times as I desire by signing, dating, and having filed with the Ohio Department of Health a denial of release form or authorization of release form prescribed and provided by the Department of Health and providing the Department two items of identification.
By signing this component of this form, I also acknowledge that I have been provided a copy of written materials about adoption prepared by the Ohio Department of Job and Family Services, the adoption process and ramifications of consenting to adoption or entering into a voluntary permanent custody surrender agreement have been discussed with me, and I have been provided the opportunity to review the materials and ask questions about the materials and discussion.
Signature of biological parent: ______________________
Signature of witness: ________________________
Date: ________________________"
(b) A component the parent signs under section 3107.071, 3107.081, or 5103.151 of the Revised Code regarding the parent's decision whether to allow identifying information about the parent contained in an adoption file maintained by the department of health to be released to the parent's child and adoptive parent pursuant to section 3107.47 of the Revised Code. The component shall be as follows:
"Statement Regarding Release of Identifying Information
The purpose of this component of this form is to allow a biological parent to decide whether to allow the Ohio Department of Health to provide an adoptee and adoptive parent identifying information about the adoptee's biological parent contained in an adoption file maintained by the Department. Please check one of the following spaces:
_______ YES, I authorize the Ohio Department of Health to release identifying information about me, on request, to the adoptive parent when the adoptee is at least age eighteen but younger than age twenty-one and to the adoptee when he or she is age twenty-one or older.
_______ NO, I do not authorize the release of identifying information about me to the adoptive parent or adoptee.
Signature of biological parent: _________________________
Signature of witness: ___________________________
Date: ___________________________"
(c) A component the parent, if the mother of the child, completes and signs under section 3107.071, 3107.081, or 5103.151 of the Revised Code to indicate, to the extent of the mother's knowledge, all of the following:
(i) Whether the mother, during her pregnancy, was a recipient of the medicaid program or other public health insurance program and, if so, the dates her eligibility began and ended;
(ii) Whether the mother, during her pregnancy, was covered by private health insurance and, if so, the dates the coverage began and ended, the name of the insurance provider, the type of coverage, and the identification number of the coverage;
(iii) The name and location of the hospital, freestanding birthing center, or other place where the mother gave birth and, if different, received medical care immediately after giving birth;
(iv) The expenses of the obstetrical and neonatal care;
(v) Whether the mother has been informed that the adoptive parent or the agency or attorney arranging the adoption are to pay expenses involved in the adoption, including expenses the mother has paid and expects to receive or has received reimbursement, and, if so, what expenses are to be or have been paid and an estimate of the expenses;
(vi) Any other information related to expenses the department determines appropriate to be included in this component.
(d) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent materials, other than photographs of the parent, that the parent requests be given to the child or adoptive parent pursuant to section 3107.68 of the Revised Code.
(e) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent photographs of the parent pursuant to section 3107.68 of the Revised Code.
(f) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent the first name of the parent pursuant to section 3107.68 of the Revised Code.
(2) State at the bottom of the form that the parent is to receive a copy of the form the parent signed.
(3) Provide copies of the form prescribed under this division to probate and juvenile courts, public children services agencies, private child placing agencies, private noncustodial agencies, attorneys, and persons authorized to take acknowledgments.
(B)(1) For a parent of a child who, if adopted, will become an adopted person as defined in section 3107.38 of the Revised Code, prescribe a form that has the following five components:
(a) A component the parent signs under section 3107.071, 3107.081, or 5103.151 of the Revised Code to attest that the requirement of division (A) of section 3107.082 or division (A) of section 5103.152 of the Revised Code has been met;
(b) A component the parent, if the mother of the child, completes and signs under section 3107.071, 3107.081, or 5103.151 of the Revised Code to indicate, to the extent of the mother's knowledge, all of the following:
(i) Whether the mother, during her pregnancy, was a recipient of the medicaid program or other public health insurance program and, if so, the dates her eligibility began and ended;
(ii) Whether the mother, during her pregnancy, was covered by private health insurance and, if so, the dates the coverage began and ended, the name of the insurance provider, the type of coverage, and the identification number of the coverage;
(iii) The name and location of the hospital, freestanding birthing center, or other place where the mother gave birth and, if different, received medical care immediately after giving birth;
(iv) The expenses of the obstetrical and neonatal care;
(v) Whether the mother has been informed that the adoptive parent or the agency or attorney arranging the adoption are to pay expenses involved in the adoption, including expenses the mother has paid and expects to receive or has received reimbursement for, and, if so, what expenses are to be or have been paid and an estimate of the expenses;
(vi) Any other information related to expenses the department determines appropriate to be included in the component.
(c) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent materials, other than photographs of the parent, that the parent requests be given to the child or adoptive parent pursuant to section 3107.68 of the Revised Code.
(d) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent photographs of the parent pursuant to section 3107.68 of the Revised Code.
(e) A component the parent may sign to authorize the agency or attorney arranging the adoption to provide to the child or adoptive parent the first name of the parent pursuant to section 3107.68 of the Revised Code.
(2) State at the bottom of the form that the parent is to receive a copy of the form the parent signed.
(3) Provide copies of the form prescribed under this division to probate and juvenile courts, public children services agencies, private child placing agencies, private noncustodial agencies, attorneys, and persons authorized to take acknowledgments.
(C) Prepare the written materials about adoption that are required to be given to parents under division (A) of section 3107.082 and division (A) of section 5103.152 of the Revised Code. The materials shall provide information about the adoption process, including ramifications of a parent consenting to a child's adoption or entering into a voluntary permanent custody surrender agreement. The materials also shall include referral information for professional counseling and adoption support organizations. The director shall provide the materials to assessors.
(D) Adopt rules in accordance with Chapter 119. of the Revised Code specifying the documents that must be filed with a probate court under divisions (B) and (D) of section 3107.081 of the Revised Code and a juvenile court under divisions (C) and (E) of section 5103.151 of the Revised Code.

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