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STATE OF WISCONSIN CIRCUIT COURT DOUGLAS COUNTY In Re: The Adoption of: REQUEST FOR ADOPTION RECORD (name of person adopted) Case Date of 1. I am the of adopted) 2. He/she was adopted in Douglas County, Wisconsin. 3. I am requesting (how many?) certified copy/copies of the Order for Adoption for the following reason: Social Security Administration Update school records Update medical records ______Other Signature Name printed/typed Address Telephone number COURT OFFICIAL USE ONLY Request for certified copy of Order for Adoption is: Approved____ Denied_____ Dated: Circuit Court Judge PROBATE OFFICE: Identification verified: (Other) Certified copy delivered to: Date: By