State of Florida Department of Health - Office of Vital Statistics CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION (Important ­ Read Information and Instructions on reverse side before completion.) A. INFORMATION REGARDING ORIGINAL STATUS OF CHILD First Middle Last City First First Middle Middle Last Name Prior to First Marriage (if applicable) Last Name Prior to First Marriage (if applicable) Birth Certificate No. __________________ (If Known) 1a. Child's Name___________________________________________________________________ 1b. Child's Sex _________________ State Country 1c. Child's Date of Birth _______________________ 1d. Child's Place of Birth _________________________________________________ 2a. Name of Father/Parent ____________________________________________________________ 2b. Father's/Parent's Race ____________ Suffix Suffix 3a.Name of Mother/Parent ____________________________________________________________ 3b. Mother's/Parent's Race ___________ B. INFORMATION FOR A NEW CERTIFICATE OF BIRTH 1. Child's Name After Adoption _________________________________________________________________________________________ (As shown in Final Judgment of Adoption) First Middle Last Suffix FATHER/PARENT 2a. Name: _________________________________________________ First Middle Last Suffix 2b. Name prior to first marriage (if applicable) ____________________________ First MOTHER/PARENT 3a. Name: _______________________________________________ Middle Last Suffix 3b. Name prior to first marriage (if applicable) __________________ 3c. Birth Date: ___________________________________________ 3d. Birth Place: __________________________________________ 3e. Race: _______________________________________________ 3f. Social Security Number: ________________________________ 2c. Birth Date: __________________________________________ 2d. Birth Place: __________________________________________ 2e. Race: _______________________________________________ 2f. Social Security Number: ________________________________ 4. Residence Address of Adoptive Parent(s) at Time of Adoption: _________________________________________________________________________________________________________________ Street, Apt. No. or Rural Route Number City, Town, or Location County State Inside City Limit Zip Code 5. Mailing address if different from residence address: __________________________________________________________________________________________________________________ 6. Is this a single parent adoption? 7. Is this a stepparent or other relative adoption? 8. Person completing Part A and B of this Form: 8a. Name: ______________________________________________ Type or Print Signature of Person Completing Form Yes Yes No No If yes, please state relationship _____________________ 8b. Relationship/Title _____________________________________ (If agency, list agency name & License #) 8d. Telephone ______________________________ Area Code and Number 8c. Signature ____________________________________________________________ 9a. Attorney/Pro Se Petitioner__________________________________9b.Bar No.__________ 9c.Telephone ____________________________ Type or Print Area Code and Number 9d. Address __________________________________________________________________________________________________________ Street City State Zip Code "For infant adoptions: If you are interested in obtaining information on Florida's Health Start Program and potential services available for your infant, please call the Healthy Baby Hotline at 1-800-45- BABY (1-800-451-2229) and identify yourself as an adoptive parent." C. CERTIFICATE OF CLERK OF CIRCUIT COURT Court Docket No._________________________ 1. On the _______ day of ______________________, 20_____, the Circuit Court of _________________________ County, _______________ Judge _______________________________ presiding, ordered a decree of adoption in the case of the child and the parents described above. 2a. Signed and Sealed by _________________________________________ Clerk of Circuit Court 2b. Date ____________________________________________ FEE: State Law requires a $20.00 fee made payable to "The Office of Vital Statistics" for filing a new birth certificate for a Florida birth resulting from adoption. This fee includes the issuance of one certification of the new certificate. Certification of the new certificate cannot be provided prior to the payment of this fee. DH 527, 04/2016, Florida Administrative Code Rule 64V-1.0031 (Obsoletes Previous Editions) American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS TYPE OR PRINT IN BLACK INK (Prompt submission of this statement, when properly completed, will ensure the timely filing of a new birth certificate.) Pursuant to s. 63.152, Florida Statutes, within 30 days after entry of a judgment of adoption, the clerk of the court, and in agency adoptions, any child-placing agency licensed by the department, shall prepare a certified statement of the entry for the State Registrar of Vital Statistics on a form provided by the registrar. A new birth record containing the necessary information supplied by the certificate shall be issued by the registrar on application of the adoptive parent(s) or the adopted person. Provide all information. This will ensure timely filing of a new birth certificate. Providing contact information is critical in case contact with the person completing the form and/or the attorney is needed to obtain additional or clarifying information. Section B. Complete all information regarding both mother/parent and father/parent regardless of whether a stepparent adoption or two new parents. This information is required for completion of a new birth certificate. In the case of a stepparent adoption, the information allows us to verify information already on file. Fee: If the fee is accompanying this statement, please DO NOT send cash. Please send a check or money order made payable to the Office of Vital Statistics. DH Form 429, Application for Amendment to Florida Birth Record, should be used when remitting the fee. This will ensure that the new certificate is mailed to the appropriate party as listed on the application. If the fee is not remitted at the time of the submission of this statement, the birth record, if the birth occurred in Florida, shall be amended and the record flagged for collection of the Amendment/Processing fee at the time certification of the new record is requested. Upon receipt of the report of adopt