ADOPTION REPORT REQUIRED TO ESTABLISH A NEW MICHIGAN BIRTH RECORD (To Be Submitted By The Court) Has it been requested that a new certificate NOT be created? Yes If yes, the adoption does not need to be reported to the Vital Records Program. No PLEASE TYPE OR PRINT CLEARLY AND LEGIBLY INFORMATION REQUIRED TO CREATE THE ADOPTIVE BIRTH RECORD Child’s Name First Middle Last MOTHER PARENT(S) INFORMATION* FATHER Current Legal Name First Middle Last Name Before First Married First Middle Last Month Day Year Date of Birth First Middle Last Month Day Year State of Birth (or country, if not USA) * Check here if the parents should be listed as ‘Parent” and ‘Parent’ rather than ‘Mother’ and ‘Father.’ ** If the child’s date of birth is prior to 1989, the mother’s current legal name will not appear on a certified copy of the birth record, and the parents’ ages will appear rather than their dates of birth. PARENT(S) INFORMATION Parents(s) name and complete mailing address are needed to mail the new record. Please provide a phone number to contact you if there are questions regarding the new record. Name(s): Mailing Address: City / State / Zip: Daytime Phone to Contact You: Area Code & Number PAYMENT - The fee for establishing a new Michigan birth record following an adoption is $40.00 and includes one copy of the new record. Additional copies of the new record are available for $12.00 each when ordered at the same time. Payment must be made by check or money order and made payable to the “State of Michigan.” The new birth record will not be created until the recording fee has been paid. Establish New Birth Record $40.00 $40.00 Following an Adoption (Fee includes on (1) certified copy of the record). Additional Certified Copies TOTAL ENCLOSED $ 12.00 Each $ - - SIGNATURE(S) Personal data of adoptive parents and child’s name after adoption should be reviewed and signed before the section for “Information Needed to Identify Original Birth Record” is completed. The form should be signed by the adoptive parent(s). The adoptive parent(s) should verify information listed for the adoptee. Ø Signature of Person Adopting Ø Signature of Husband, Wife or Other Person Adopting $ American LegalNet, Inc. www.USCourtForms.com INFORMATION NEEDED TO IDENTIFY ORIGINAL BIRTH RECORD Child’s Name at Birth First Middle Male Child’s Gender Last Female Child’s Date of Birth Month Day Child’s Place of Birth City County First Middle Year Name of Birthing Hospital (If Available) Biological Mother’s Name Before First Married Last COURT CERTIFICATION The Family Division of Circuit Court of County, Michigan I hereby certify that the child name above was adopted in accordance with Michigan Law on (Month, Day, Year) by the parent(s) listed as the parent(s) for the adoptive birth record, as set forth in the final decree of adoption. CASE NO. Judge By Clerk of the Court SEAL For additional information: Vital Records Changes (517) 335-8660 Mon-Fri 8:00 am - 5:00 pm ET MAIL REPORT AND PROPER FEE TO: Vital Records Changes P.O. BOX 30721 Lansing, MI 48909 DCH-0854 Rev 01/2005 MCL 333.2829(1), MCL 333.283(a) and 333.2891(9)(a) American LegalNet, Inc. www.USCourtForms.com