ILLINOIS DEPARTMENT OF PUBLIC HEALTH Division Of Vital Records 605 W. Jefferson St. Springfield, IL 62702-5097 CERTIFICATE OF ADOPTION CHILD’S INFORMATION AT BIRTH Name _______________________________________________ Date of birth _______________________ State file number __________________ Place of birth Hospital, city state and country __________________________________________________________________________________ Mother’s full name _________________________________________ ❏ Male ❏ Female Father’s full name _________________________________________________ ❏ Yes If foreign born, has Illinois previously created a birth record for this child? Has any U.S. state previously created a birth record for this child? ❏ Yes ❏ No ❏ No If yes, what state? ______________________ CHILD’S NAME AFTER ADOPTION First name(s) _____________________________ Middle name(s) ___________________________ Last name(s) __________________________ PARENT’S INFORMATION AFTER ADOPTION ❏ Co-parent ❏ Natural father ❏ Adoptive father ❏ Single father ❏ Co-parent ❏ Natural mother ❏ Adoptive mother ❏ Single mother Full maiden name _____________________________________ Full maiden name_____________________________________ Date of birth __________________________________________ Date of birth _________________________________________ Place of birth _________________________________________ Place of birth ________________________________________ Social Security number _________________________________ Social Security number ________________________________ Signature of this parent ___________________________________________ Signature of this parent___________________________________________ By signing this form, you are verifying that all information listed is true and correct. By signing this form, you are verifying that all information listed is true and correct. ADDRESSES Adoptive parent(s)’ address at the time of this child’s birth. Street ______________________________________________________ City ____________________________________ State ________ ZIP Code____________ County________________________ Attorney’s address and telephone number _________________________________________________________________________ Adoptive parent(s) current mailing address and telephone number__________________________________________________________________________________ Do you want a new birth certificate created? ❏ Yes ❏ No If yes, send the new birth certificate to ❏ Attorney ❏ Parents CERTIFICATION State of Illinois, County of _______________________________ Case Number _________________ Decree Date ____________ I hereby certify that a decree of adoption was entered by the Circuit Court of this county on the above listed date which adjudged that the above mentioned child is deemed to be for legal intents and purposes the child of the adoptive parents identified above. Date___________________________________ COURT SEAL Signed _________________________________ American LegalNet, Inc. www.USCourtForms.com ILLINOIS DEPARTMENT OF PUBLIC HEALTH Division Of Vital Records 605 W. Jefferson St. Springfield, IL 62702-5097 CERTIFICATE OF ADOPTION The certificate of adoption must be completed in its entirety. Failing to complete any portion of this form could result in the document being returned to you without the adoption information being placed on the birth record. The fee for completing the birth record of an Illinois born child is $15. This includes one certified copy of the new birth certificate. Additional copies ordered at the same time are $2 each. Make check or money order payable to Illinois Department of Public Health or IDPH. If you are submitting a certificate of adoption regarding a foreign born child, you must submit one additional document as proof of the child’s place and date of birth. Records of foreign birth are $5 each. If the adopted child was born in a state other than Illinois, this certificate of adoption will be forwarded to the state of birth. Please type or print all information clearly. If you have additional questions, call the Division of Vital Records at 217-782-6553. Office hours are 8:30 a.m. to 4 p.m., Monday through Friday. Child’s information at birth Indicate the child’s full name at birth; month, day and year of birth; hospital, city, state and country (if other than the United States) of birth. If the state file number of the birth record is known, indicate so. Provide the full names of the biological mother and father. Indicate the sex of the child. If you are submitting an adoption regarding a foreign born child, has the state issued a birth record for this child in connection with a prior adoption in Illinois? If you are submitting an adoption regarding a foreign born child, has any state in the United States previously established a birth record for this child? If so, in what state. Child’s name after adoption Indicate in the appropriate space the child’s first, middle and last name(s). Do not use white out or line through any part of the new name. If alterations are made, a certified copy of the adoption decree will be required. Parent’s information after adoption Indicate if each parent is a co-parent, natural father, natural mother, adoptive father or adoptive mother, or if this is a single parent adoption. Give each parent’s first, middle and last (maiden) surname. Provide each month, day and year of birth; and the state or country (if other than the United States) of birth for each. Each parent’s Social Security number is required; if either parent does not have a Social Security number, please so indicate. Each parent must sign verifying his/her respective information. Addresses The address of the adoptive parent(s) at the time of the child’s birth is required. Provide the complete address including any apartment number, city, state, ZIP code and county. If the biological mother is also a parent after adoption, then her address from the original birth record will be placed on the new birth record. The attorney’s complete address and telephone number are required. The current address and telephone number of the adoptive parent(s) are also required. Indicate if a new birth record is to be created and to whom it is to be sent. Certification This must be completed by the circuit clerk’s office in the county where the adoption was completed. The circuit clerk must include his/her seal. Printed by Authority of the State of Illinois P.O. #145077 20M 7/04 VR 160 American LegalNet, Inc. www.USCourtForms.com