Print Form State Adoption File Number: Certificate of Adoption 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 Child-Placing Agency Representative (as applicable) and filed along with the petition or decree. When the final order of adoption has been decreed, the Clerk of Court shall complete the certification information below in Part III. The Clerk shall affix the Seal of Court, sign the certification and forward this certificate to: Vital Records Service, 2600 Skyland Drive N.E., Atlanta, Georgia 30319-3640. Part I - Before Adoption NAME OF CHILD AT BIRTH (FIRST, MIDDLE, LAST) SEX 2. 1. DATE OF BIRTH (MO., DAY, YR.) 3. PLACE OF BIRTH (CITY, COUNTY, STATE) 4. ORIGINAL BIRTH CERTIFICATE NO. 5. MAIDEN NAME OF NATURAL MOTHER (FIRST, MIDDLE, LAST) NAME OF NATURAL FATHER (FIRST, MIDDLE, LAST) 6. 7. Part II - After Adoption - Information for New Birth Certificate NAME OF CHILD AFTER ADOPTION (FIRST, MIDDLE, LAST) 8. MAIDEN NAME OF MOTHER (FIRST, MIDDLE, LAST) MOTHER (CHECK ONE) Adoptive 9b. 9a. MOTHER - DATE OF BIRTH (MO., DAY, YR.) MOTHER - PLACE OF BIRTH (STATE OR COUNTRY) 9c. 9d. Natural CITZEN OF US? Yes 9e. No RESIDENCE OF ADOPTIVE MOTHER AT TIME OF CHILD'S BIRTH (STREET OR R.F.D. NO., CITY, TOWN, STATE, ZIP) 9f. COMPLETE NAME OF FATHER (FIRST, MIDDLE, LAST) FATHER (CHECK ONE) 10b. 10a. FATHER - DATE OF BIRTH (MO., DAY, YR.) FATHER - PLACE OF BIRTH (STATE OR COUNTRY) 10c. 10d. Adoptive Natural CITZEN OF US? 10e. Yes No CURRENT ADDRESS OF ADOPTIVE PARENTS (STREET OR R.F.D. NO., CITY, TOWN, STATE, ZIP) 11. A NEW BIRTH CERTIFICATE IN THE ADOPTED CHILD'S NEW NAME WHICH SHOWS THE ADOPTIVE PARENT'S NAMES WILL BE PREPARED UNLESS THIS BOX IS CHECKED. 12. SIGNATURE OF INFORMANT TITLE OF INFORMANT 13a. 13B. TYPEOR PRINT ATTORNEY'S NAME 13c. TYPE OR PRINT ATTORNEY'S ADDRESS (STREET OR R.F.D. NO., CITY, TOWN, STATE, ZIP) 13d. PART III - CERTIFICATION INFORMATION DATE DECREE ENTERED (MO., DAY, YR.) COURT FILE NO. 14. 15. COUNTY OF COURT 16. THE PLACE OF BIRTH SHALL BE AS INDICATED ON THE FINAL DECREE OF ADOPTION I HEREBY CERTIFY THAT THE FINAL DECREE OF ADOPTION CONCERNING THE ABOVE NAMED PERSONS WAS ENTERED IN THIS COURT. 17. 18. (CITY) FORM 3927 (REV. 3-01) (COUNTY) (SIGNATURE OF CLERK) (PLACE OF SEAL OVER SIGNATURE) GEORGIA DEPARTMENT OF HUMAN RESOURCES / VITAL RECORDS SERVICE American LegalNet, Inc. www.FormsWorkflow.com