Probate Court of Lake County,Ohio MARK J. BARTOLOTTA, JUDGE IN THE MATTER OF THE ADOPTION OF ___________________________________________ Case No: __________________ PETITION FOR FOREIGN BIRTH RECORD (R.C. 3107.18) (Check applicable boxes, complete applicable blanks, strike applicable language, and attach supporting documentation) The Petitioner(s) is/are the adoptive parent(s) of a minor child pursuant to a foreign decree or certificate of adoption and state that: PETITIONER(S) Petitioner's Full Name: ___________________________________________________ Petitioner's Full Name: ___________________________________________________ Residence: ____________________________________________________________ Duration of Residence: ___________ Marital Status: ___________ Date and Place of Marriage: _______________________________________________ ADOPTED CHILD Name of Child Before Adoption: ____________________________________________ Name of Child After Adoption: _____________________________________________ Date and Place of Birth: __________________________________________________ ATTACHED IS A CERTIFIED COPY OF THE CHILD'S BIRTH CERTIFICATE, AND IF NOT IN ENGLISH, ALSO ATTACHED IS A TRANSLATION CERTIFIED AS TO ITS ACCURACY BY THE TRANSLATOR. American LegalNet, Inc. www.FormsWorkFlow.com ATTACHED IS A CERTIFIED COPY OF THE FOREIGN DECREE OR CERTIFICATE OF ADOPTION WHICH HAS BEEN VERIFIED AND APPROVED BY THE DEPARTMENT OF HOMELAND SECURITY OF THE UNITED STATES, AND IF NOT ENGLISH, ALSO ATTACHED IS A TRANSLATION CERTIFIED AS TO ITS ACCURACY BY THE TRANSLATOR. Attached is a fully completed Ohio Department of Health, Division of Vital Statistics, Certificate of Adoption Form HEA 2757. The Petitioner(s) state that giving effect to the Foreign Decree or Certificate of Adoption would not violate the public policy of the State of Ohio and respectfully pray for the following Order(s). ( ) An Order that the child's name shall be changed to: ________________________________________________________________________ ________________________________________________________________________ ( ) An Order to the Department of Health to issue a foreign birth record for the adopted person under R.C. 3705.12(A)(4). ( )___________________________________________________________________ _______________________________ Attorney for Petitioner(s) _______________________________ Typed or Printed Name _______________________________ Address _______________________________ City, State, Zip _______________________________ Phone # (include area code) _______________________________ Attorney Registration Number _________________________________ Petitioner (signature) _________________________________ Petitioner (signature) _________________________________ Address _________________________________ City, State, Zip _________________________________ Phone # (include area code) _________________________________ Work # (include area code) Print Reset American LegalNet, Inc. www.FormsWorkFlow.com