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Directory Results for Print Certificate of Adoption State Adoption File Number: Type or Print All Information in Blue - Black Permanent Ink Parts I and II of this certificate are to be completed by the Petitioner, Attorney for the Petitioner, or the to Print CERTIFICATE OF INSURANCE REQUEST FORM Client Information Name: Address: City, State, Zipcode: Phone #: Policy Information Insurance Company(ies): Policy Number(s): Effective Date of request: Recipient Information Name: Address: Fax Number: