STATE OF MICHIGAN DEPARTMENT OF PUBLIC HEALTH RECORD OF ADOPTION PART A 1. CHILD - NAME AFTER ADOPTION 2. SEX INFORMATION NEEDED TO PREPARE NEW BIRTH CERTIFICATE IN ADOPTIVE STATUS (FIRST) (MIDDLE) (LAST) 3a. THIS BIRTH - SINGLE, TWIN, ETC. 3b. IF NOT SINGLE, BORN 1 , 2 , etc. ST ND 4a. DATE OF BIRTH 4b. TIME OF BIRTH 5a. CITY, VILLAGE, OR TOWNSHIP OF BIRTH 5b. COUNTY OF BIRTH 5c. STATE OF BIRTH 6a. MOTHER - PRESENT NAME (First, Middle, Last) 6b. SOCIAL SECURITY NO. 6c. DATE OF BIRTH 6d. STATE OF BIRTH NAME OF COUNTRY IF NOT USA 6e. RESIDENCE (Check one box and specify) INSIDE CITY OR VILLAGE OF TWP. OF AT TIME OF THIS BIRTH COUNTY AT TIME OF BIRTH STATE AT TIME OF BIRTH 6h. STREET AND NO. AT TIME OF BIRTH 6i. MOTHER'S SURNAME BEFORE FIRST MARRIAGE 7a. FATHER - NAME (First, Middle, Last) 7b. SOCIAL SECURITY NUMBER 7c. DATE OF BIRTH 7d. STATE OF BIRTH NAME OF COUNTRY IF NOT USA PERSONAL DATA OF ADOPTIVE PARENTS AND CHILD'S NAME AFTER ADOPTION SHOULD BE REVIEWED, SIGNED (CURRENT NAMES AND VERIFIED, IF POSSIBLE, BY THEM BEFORE PART B IS COMPLETED). HAS IT BEEN REQUESTED THAT A NEW CERTIFICATE NOT BE CREATED? MOTHER'S SIGNATURE PART B FATHER'S SIGNATURE Yes or no INFORMATION NEEDED TO INDENTIFY ORGINIAL BIRTH CERTIFICATE Child's name at birth Maiden name of natural mother PART C Birth Certificate number (if known) COURT CERTIFICATION Family Court County, Michigan I hereby certify that the child named above was adopted on By the persons listed under items 6 and 7 above, as set forth in the final degree of adoption. Case no. Judge SEAL By: Probate Register or Clerk of the Court By authority of Act 368 Public Acts 1978 Failure to provide the required information is a misdemeanor punishable by imprisonment of not more than 1 year or a fine of not more than $1,000.00 or both. Please provide mailing address of adoptive parents in order that we may forward them a copy of the new birth certificate. (see reverse side for additional information required for those children born in other states) B-83A (1/89) American LegalNet, Inc. www.FormsWorkflow.com MOTHER Race of adoptive mother Occupation Kind of business or industry Children born previously to this mother Born alive, now dead Born dead Education FATHER Race of adoptive father Occupation Kind of business or industry Education Do parents wish to have a new birth certificate issued: Is this a step-parent adoption: If so, stepfather stepmother Signature of adopting parents (mother) (father) (See chart listing requirements of individuals states) ADOPTION UNIT OFFICE OF THE STATE REGISTRAR MICHIGAN DEPARTMENT OF PUBLIC HEALTH 3423 NORTH LOGAN STREET P.O. BOX 30195 LANSING, MICHIGAN 48909 American LegalNet, Inc. www.FormsWorkflow.com