Commonwealth of Massachusetts
Juvenile Court Department

 Division

RE:

In the Matter of the Adoption of

AUTHORIZATION FOR CRIMINAL RECORD CHECK

I  hereby  authorize  the  Juvenile  Court  to  conduct  a  criminal  record  check  to  determine
whether I have a criminal record.  I understand the criminal record check is intended for
use by the court in conjunction with my petition to adopt the above named child.  I further
understand that the court will not consider my petition for adoption without conducting a
criminal record check of both petitioners. Therefore, the information below is willingly
supplied by me, and my signature indicates my permission for this record check to be
completed.

Male   

Date of Birth:

Female 

Name:
Current Address:
Social Security No.:
Gender:
Place of Birth:
Maiden Name (if applicable):
Other Names or Aliases used:
Mother's Name:
Father's Name:

Date:

(Signature)

NOTARIZATION

The above signed made oath before me on ______________________ that this affidavit
is her/his free act and deed.
Notary  Public:  ________________________
Print  Name:  __________________________
My Commission Expires: _______________

JV-Authorization for Criminal Record Check (02/25/2009)



Authorization for Criminal Record Check

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• Sourced from www.mass.gov (2023-03)
• Page(s): 1
• Fields(s): 14
• Average fields per page: 14
• Reading Level: Grade 9
• LIST Grouping(s): GO-00-00-00-00.

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