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Internal Affairs Te Tari Taiwhenua

BDM404

Application by Donor Offspring (or Guardian) to Access Information held on the Human Assisted Reproductive Technology Register.

Complete and post to HART Team, Births, Deaths & Marriages (HART), PO Box 10526, Wellington 6143.
Please attach a certified copy of an identity document belonging to the person who is making the request. 

Person making application.
This request is being made by:
Donor offspring aged 18 years or older. Yes or No ^ 
Donor offspring aged 16 or 17 years, authorised by Family Court (Please attach copy of Court order). Yes or No ^
Donor offspring aged under 18 years, for information that does not identify donor. Yes or No ^
Guardian of donor offspring aged under 18 years. Yes or No ^
Agent (e.g. lawyer) acting on behalf of a donor offspring or donor offspring’s guardian. (The “Authorisation for Disclosure of Information to Agent” form BDM 405 must be completed). Yes or No ^

Benefit of counselling.
It is strongly recommended that you consult with a counsellor of your choice before submitting this form. Counselling helps people to consider the implications of accessing information about a donor or other donor offspring who are related to the same donor(s), and contacting those people. Counsellors can answer questions about how others have approached the issue, and what seems to work best. Counselling may be arranged through your fertility service provider, or with an independent counsellor.

Personal and address details. 
Current first name(s) of donor offspring. ^
Current surname of donor offspring. ^
Donor offspring’s date of birth. ^
First name(s) and surname of guardian (if guardian is completing the application where donor offspring is aged under 18). ^
Fertility service provider (and branch, if relevant). ^
Donor offspring identifier (if known). ^
Address information being posted to. ^
Daytime contact telephone number. ^
Email. ^

Information requested (Restrictions on disclosure of some types of information may apply). 
A printout containing all or any of the following costs $40.80 

Information relating to the donor offspring who is the subject of the application. Yes or No ^
Information relating to the donor(s) of the donor offspring. Yes or No ^
Information relating to other donor offspring related to the same donor. Yes or No ^

A printout containing the following information: $15.30 (or no extra fee, if requested with the above same products). 
Whether a donor has asked for information about the donor offspring. Yes or No ^
Whether information is held about the donor(s) of the donor offspring. Yes or No ^
Whether the donor offspring shares a donor with other donor offspring. Yes or No ^

Payment Details (All Fees Must be Pre-Paid). 

I enclose a NZ cheque/NZ money order (payable to the Department of Internal Affairs) for $ ^
or
Please debit my 
Visa Yes or No ^
Mastercard Yes or No ^
Amex Yes or No ^
for $ ^
Credit card number ^
Cardholder name and signature ^

Sections 57, 58, 63(8), 63(9) of the Human Assisted Reproductive Technology Act 2004.