COURT REPORT OF ADOPTION ___________________________ ___________________________ NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS STATE FILE NUMBER LOCAL REGISTRATION NUMBER TYPE OR PRINT CLEARLY IN BLACK INK ONLY PART I The information provided in this section must be the information as it was at birth. Without this data, it may be impossible to prepare a new Certificate of Birth. 1A. NAME OF CHILD—FIRST FACTS OF BIRTH 2. SEX 3. DATE OF BIRTH—MM/DD/CCYY 1B. MIDDLE 1C. LAST (BIRTH) 4. NAME OF PHYSICIAN (OR ATTENDANT, CERTIFIER, OR OTHER PERSON WHO ATTENDED THIS BIRTH) 5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY 5B. CITY 5C. STATE OR COUNTRY 6A. FULL NAME OF FATHER/PARENT—FIRST PARENTS’ DATA PART II 6B. MIDDLE 6C. LAST (BIRTH) 7A. FULL NAME OF MOTHER/PARENT—FIRST 7B. MIDDLE 7C. LAST (BIRTH) Adoptive parents must furnish personal information about themselves as it was on the child’s date of birth. This information is used to prepare the new Certificate of Birth. CHECK THE APPROPRIATE BOX: ADOPTIVE FATHER/PARENT FATHER/ PARENT INFORMATION 8A. NAME OF FATHER/PARENT—FIRST □ BIOLOGICAL FATHER/PARENT 8B. MIDDLE 8C. LAST (BIRTH) 9. STATE/FOREIGN COUNTRY OF BIRTH 10. DATE OF BIRTH—MM/DD/CCYY CHECK THE APPROPRIATE BOX: ADOPTIVE MOTHER/PARENT MOTHER/ PARENT INFORMATION 11A. NAME OF MOTHER/PARENT—FIRST □ □ BIOLOGICAL MOTHER/PARENT 11B. MIDDLE □ 11C. LAST (BIRTH) 12. STATE/FOREIGN COUNTRY OF BIRTH 13. DATE OF BIRTH—MM/DD/CCYY 14. PLEASE CHECK ONE I want the original birth certificate sealed, and a new birth certificate established. . . . . . . Pursuant to Health and Safety Code Section 102640, I choose not to have a new birth certificate established. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ □ 15. Do you want the name of the hospital or other facility where birth occurred omitted from the new birth certificate as provided for in Section 102645 of the Health and Safety Code? (PLEASE CHECK ONE) YES □ NO □ VERIFICATION OF PART II 16. SIGNATURE OF PARENT VERIFYING DATA IN PART II AGENCY OR DEPARTMENT 18A. NAME OF AGENCY OR DEPARTMENT 18B. MAILING ADDRESS OF AGENCY/DEPARTMENT THAT INVESTIGATED/HANDLED THE ADOPTION 19A. SIGNATURE AND PRINTED NAME OF ATTORNEY 19B. MAILING ADDRESS OF ATTORNEY ATTORNEY 17. MAILING ADDRESS OF PARENT VERIFYING DATA IN PART II ► ► PART III The county clerk must obtain as much information as is available to complete Parts I and II before completing Part III and forwarding the record and Court Order/Final Decree to the State Registrar as required by law. 20. I HEREBY CERTIFY THAT THE INDIVIDUAL DESCRIBED ABOVE WAS ADOPTED BY THE ABOVE NAMED ADOPTIVE PARENTS ON THE __________________________ DAY OF _____________________________, 20________, AS SET FORTH IN THE DECREE OF ADOPTION MADE ON THAT DATE IN CASE NUMBER _____________________________ 21A. NEW NAME AS SET FORTH IN THE DECREE OF ADOPTION--FIRST 21B. MIDDLE 21C. LAST COUNTY CLERK 22. SIGNATURE AND SEAL OF COUNTY CLERK BY: ► 23. CLERK IN AND FOR THE COUNTY OF: 24. DATE SIGNED—MM/DD/CCYY 25. DATE PETITION FOR ADOPTION FILED—MM/DD/CCYY NAME NAME AND MAILING ADRESS OF PERSON TO WHOM CERTIFIED COPY IS TO BE SENT ADDRESS—Street and Number CITY, STATE, ZIP CODE STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS DAYTIME TELEPHONE NUMBER ( ) FORM VS 44 (Rev. 1/08) American LegalNet, Inc. www.FormsWorkflow.com GENERAL INFORMATION The County Clerk shall complete and transmit a court report of adoption to the Office of Vital Records for each decree of adoption granted by any court in the State of California. The Office of Vital Records shall transmit court reports of adoptions for births that occurred in another state, the District of Columbia, any territory of the United States, or Canada to the appropriate registration authority. The information contained in Part I and Part II of this certificate is required in order to identify and seal the original birth certificate and prepare a new birth certificate. Once the original birth certificate is sealed, it is only available upon order of a Superior Court. INSTRUCTIONS The agency or department handling the adoption should fill out Parts I and II, but the County Clerk may complete any incomplete items in Part I or Part II from the information furnished in the court record. When requested by the adoptive parents, the Office of Vital Records shall not establish a new birth certificate for the child. (Health & Safety Code Section 102640.) The adoptive parents should indicate in Item 14 whether they DO want a new birth certificate established (by checking the “Yes” Box) or whether they DO NOT want a new birth certificate established (by checking the “No” Box). The adoptive parents may request the Office of Vital Records to omit the specific name and address of the hospital or other facility where the birth occurred by checking the “Yes” Box in Item 15. (Health & Safety Code Section 102645.) A deceased spouse of an adopting single parent can be listed on the new birth certificate if both adopting parents were in the home at the time of the initial placement of the child for adoption. Refer to Health & Safety Code Section 102660 for additional requirements. One of the adopting parents should verify the information in Part II, sign in Item 16, and enter his or her mailing address in Item 17. The name and address of the agency or department and the attorney handling the adoption should be entered in Items 18 and 19. The applicable fee shall be paid to the County Clerk at the time of filing the petition in an adoption proceeding for the services required by statute of the State Registrar. (Health & Safety Code Section 103730.) For cases in which the petition for adoption was filed on or after January 1, 1972, and the individual was born in California or a foreign country, a certified copy of the new birth record will be furnished without additional fee as provided in Health & Safety Code Section 102710. For adoptions that occurred prior to January 1, 1972, or in another state, a fee must be submitted for processing the new birth certificate, which includes one certified copy. Additional certified copies may be obtained from the Office of Vital Records, but there is an additional fee for each additional certified copy requested. Please contact the Office of Vital Records for the current fees, or visit our website at www.cdph.ca.gov. Please do not order additional copies until you have reviewed the original copy for accuracy. The mailing address for the Office of Vital Records is: California Department of Public Health Office of Vital Records MS 5103 P.O. Box 997410 Sacramento, CA 95899-7410 American LegalNet, Inc. www.FormsWorkflow.com