OF THE DISTRICT OF COLUMBIA VITAL RECORDS FORM FOR ADOPTION PROCEEDINGS 1.Original name of child 2.Date of birth Place of birth 3.Name of Natural father 4.Name of Natural mother (including maiden name) 5.Birth certificate number if known 6.Name of child-placing agency (required only when the names of the natural parents are unknown) In order that there may be a complete record of the history of the adoptive parents as if they were the natural on the new certificate, it will be necessary that the information requested below be furnished. ADOPTIVE ADOPTIVE Full Name Date of birth Race Date of birth Birthplace Occupation Full NameRaceBirthplace Occupation Usual residence Usual residence Other children born to, or adopted by this (do not include this child): No. now living No. born alive but now dead No. born dead The items regarding the age, occupation, and residence of the adopters are to be furnished as of the date that the adoptee was born. Signed: Address: ADOPTION NO. American LegalNet, Inc. www.FormsWorkFlow.com