(A) Not later than ninety days after the effective date of this section, the department of health shall prescribe a form with which an adopted person may make a request under division (A) of section 3107.48 of the Revised Code. The form shall require all of the following information:
(1) The residence address of the adopted person;
(2) The adopted person's name and date of birth as it appears on the adopted person's new birth record;
(3) The notarized signature of the adopted person;
(4) Any other information considered necessary by the department.
(B) The form shall include instructions that explain how it is to be completed and filed with the department. The department shall include on the form information that advises the adopted person that the adopted person may, in accordance with division (B) of section 3107.48 of the Revised Code, rescind the request at any time, and shall include instructions on how to do so.
(C) On request of an adopted person, the department shall provide the adopted person with a copy of the form.
Effective Date: 06-20-1996 .