STATE OF NEW HAMPSHIRE Department of State Division of Vital Records Administration CONFIDENTIAL Report of City and Town Clerk Relative to an Adoption TYPE OR PRINT ONLY I. CHILD 1. CHILD’S (First) NAME (Middle) (Last) 2. DATE OF BIRTH CHILD 4. LOCATION (City/Town) (County) OF INFORMATION BIRTH AS IT APPEARS BEFORE 5. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND ADOPTION (Month) (Day) (Year) 3. SEX (State/Country) 6. ANCESTRY? (English, French, Puerto Rican, etc.) Specify AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 7. SIBLINGS IN SUBSTITUTE 8. MEMBER SIBLING GROUP ADOPTED 9. PREVIOUS ADOPTIVE PLACEMENT? CARE? TOGETHER? YES NO YES NO YES NO 10. SPECIAL Yes If Yes, Primary Basis: Age Racial/Ethnic Member Sibling Group Medical/Other Disability NEEDS No Other, Specify CHILD If Medical/Other, Check All That Apply Blind/Visually Impaired Deaf/Hard of Hearing Physically Disabled Mental Retardation Emotionally Disturbed Learning Disability Medical Condition Other, Specify: 11. DATE OF ADOPTIVE PLACEMENT (Month) (Day) (Year) 12. AUSPICES OF ADOPTION PUBLIC AGENCY TRIBAL AGENCY OTHER, SPECIFY INDEPENDENT PERSON PRIVATE AGENCY 13. LOCATION OF AGENCY/PERSON (State/Country) II. SUPPORT 14. ADOPTION SUBSIDY YES NO COMPLETE IF 15. SOURCES OF FINANCIAL SUPPORT (CHECK ALL THAT APPLY) STATE/FEDERAL TITLE IV-MONTHLY TITLE IV-E NON-RECURRING STATE ONLY TITLE XVI (SSI) SUPPORT FOR TITLES XIX/XX WITH NO PAYMENT NONE OF ABOVE, PARENTS ONLY CHILD OTHER, SPECIFY III. BIOLOGICAL 16. FATHER’S NAME (First) (If stated on FATHER (Middle) 17. DATE (Month) (Day) (Year) OF BIRTH 19. ANCESTRY? (English, French, Puerto Rican, etc.) Specify (Last) birth certificate) 18. WAS TERMINATION OF PARENTAL RIGHT (Month) (Day) (Year) VOLUNTARY – Date of Surrender/Consent NON-VOLUNTARY – Date of Termination of Rights NOT APPLICABLE 20. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKAN NATIVE UNKNOWN OTHER, SPECIFY 21. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION IV. BIOLOGICAL 22. MOTHER’S MAIDEN SURNAME MOTHER 23. DATE OF BIRTH 25. WAS TERMINATION OF PARENTAL RIGHT VOLUNTARY – Date of Surrender/Consent NON-VOLUNTARY – Date of Termination of Rights NOT APPLICABLE 27. RACE WHITE BLACK CHINESE/JAPANESE AMERICAN INDIAN/ALASKAN NATIVE 28. MARITAL STATUS MARRIED SEPARATED DIVORCED SINGLE (Month) (Month) (Day) (Year) (Day) (Year) 24. MOTHER MARRIED AT BIRTH OF CHILD? YES NO 26. ANCESTRY? (English, French, Puerto Rican, etc.) Specify OTHER ASIAN/PACIFIC ISLANDER UNKNOWN OTHER, SPECIFY CIVIL UNION WIDOWER CIVIL UNION DISSOLUTION (Continued on Back) PAGE 1 V.S.-37 03/08 American LegalNet, Inc. www.FormsWorkFlow.com V. ADOPTIVE 29. MOTHER’s/ (First) PARENT A’s MOTHER/ NAME PARENT A (Middle) 30. MAIDEN NAME (Last) 32. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 34. STATE OF BIRTH 35. RESIDENCE (Street Address) AT TIME OF CHILD’S BIRTH: 36. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION VI. ADOPTIVE 38. FATHER’s/ (First) FATHER/ PARENT A’s NAME PARENT B (Middle) 33. ANCESTRY? (English, French, Puerto Rican, etc.) Specify (City/Town) (County) 37. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE 39. MAIDEN NAME (Last) WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 43. STATE OF BIRTH 44. RESIDENCE (Street Address) AT TIME OF CHILD’S BIRTH: 45. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION INCOME 47. FAMILY INCOME OF ADOPTIVE PARENTS Under $25,000 $35,000 – $44,999 (State) BIOLOGICAL MOTHER CO-PARENT 40. DATE (Month) (Day) (Year) OF BIRTH (If applicable) 41. RACE VII. 31. DATE (Month) (Day) (Year) OF BIRTH (If applicable) 42. ANCESTRY? (English, French, Puerto Rican, etc.) Specify (City/Town) (County) 46. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE $25,000 – $34,999 $45,000 – $54,999 (State) BIOLOGICAL FATHER CO-PARENT $55,000 and over VIII. ADOPTIVE 48. PARENTS WE DO NOT WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION. WE WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION. A NEW BIRTH CERTIFICATE IS PREPARED FOR THE ADOPTEE AFTER THE ADOPTION IS GRANTED. WE REQUEST THAT THE AMENDED BIRTH RECORD BE PREPARED TO SHOW THE PARENT’S NAMES AND THE NAME OF THE ADOPTEE AS FOLLOWS: 49. MOTHER’S/PARENT A’s NAME (First) (Middle) (Last) 50. FATHER’S/PARENT B’s NAME (First) (Middle) (Last) (First) (Middle) (Last) CHILD’S 51. ADOPTEE’S NAME ADOPTED NAME 52. CURRENT MAILING ADDRESS (R.F.D., or St. or Box No.) (City/Town) (State) IX. ADOPTIVE 53. PERSONAL SIGNATURE OF ONE OR BOTH OF THE ADOPTIVE PARENTS PARENTS’ MOTHER/PARENT A FATHER/PARENT B SIGNATURE X. PROBATE 54. On the day of , 20 , the COURT OR County, in the State of , FAMILY (Name of Justice or Judge) DIVISION adoption in the case of the child and parents described above, recorded by microfilm or in Vol. , Page (Zip Code) Court of presiding, passed a decree of , Record No. Signed and sealed by: Date: 20 (Judge, Register, Clerk) NOTE: When adoption takes place in New Hampshire and the child was born in New Hampshire, the court will forward copies of the adoption report as shown. If the adoptee was not born in New Hampshire, the court will forward copies of the adoption report to the Division of Vital Records Administration, who will forward the report to the respective state of birth. a. Report sent to town clerk of SEAL Date: XI. CITY/TOWN CLERK , 20 b. Report sent to Div. of Children & Youth Services , 20 c. Report sent to New Hampshire Division of Vital Records Admin. , 20 To be completed by New Hampshire Town/City Clerk of Place of Birth 55. Date received 56. Date forwarded to Div. of Vital Records Admin. 57. Signed Clerk of American LegalNet, Inc. www.FormsWorkFlow.com PAGE 2 V.S.-37 03/08