NHJB-2420-FP (06/04/2008) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) REQUEST FOR CERTIFICATE OR COPY 1. Person making request Telephone number Mailing address 2. I request the following certificates or copies: Certificate of Name Change Quantity Certificate of Appointment Quantity Certificate of Adoption Quantity (See #3 below) Certified copy - list documents Quantity Quantity Quantity Plain copy 226 list documents Quantity Quantity Quantity Quantity Other 226 explain Quantity Quantity 3. For a Certificate of Adoption, please check one of the following: I am the adoptee identified in the certificate, and I am age 18 or older. I am the adoptive parent of the adoptee identified in the certificate, and this adoptee is under the age of 18. 4. For all requests, please check one of the following: I will pick up these certificates or copies. Please mail the certificates or copies to the address indicated in #1 above. Date Signature To be completed by Court Staff Type of Proof of Identification provided Amount paid: Payment made by: Check Cash Credit Card Date sent or picked up: Issued by: American LegalNet, Inc. www.FormsWorkFlow.com