PH-1248 (Rev. 06/17) RDA 10128 STATE OF TENNESSEE DEPARTMENT OF HEALTH, OFFICE OF VITAL RECORDS CERTIFICATE OF ADOPTION INSTRUCTIONS: USE BLACK INK OR TYPEWRITER TO COMPLETE THIS FORM. DO NOT USE WHITEOUT OR ANY ERASURE. Part I should be completed and signed by the adopting parents . Parts II and III should be completed by attorney, clerk of court, or child placing agency. When the final decree of adoption has been entered, the clerk of court shall enter his/her certification in Part IV, affix th e seal of the court, sign, and forwa rd to Tennessee Vital Records, Andre w Johnson Tower, 1 st Floor, 710 James Robertson Parkway, Nashville, TN 3724 3 . If the child was born in another state or U. S. Territory, the office will forward to the proper state. If the child was born in Tennessee, enclose the fee of $ 30 .00 for preparation of a new birth record. The fee entitles applicant to one certified copy of the new birth certificate. Additional copies may be obtained at the same time for $ 1 5 .00 each. Make check or money order payable to Tenn essee Vital Records . INFORMATION AFTER ADOPTION PART I All items must be completed so that the new birth certificate will show all essential data Adoptive parents should verify all personal data for accuracy and sign this form before Part II is c ompleted. Full name of child after adoption, as decreed by court. ADOPTIVE FATHER Were you related to this child prior to adoption? Yes No If so, what is your relation? Full Name of Father Date of Birth (Mo/Day/Year) State or Foreign Country of Birth Social Security Number ADOPTIVE MOTHER Were you related to this child prior to adoption? Yes No If so, what is your relation? Fu ll Legal Name of Mother Maiden Surname of Mother Date of Birth (Mo/Day/Year) State or Foreign Country of Birth Social Security Number Zip Cod e) Inside the city limits? YES NO County of Residence I have reviewed the information entered in Part I and verify that it is accurate. Note: stepparent) is the adopting parent, both the stepparent and biological parent should complete Part I. Date Date Do you want a new birth certificate prepared? YES NO. YES NO INFORMATION ABOUT CHILD BEFORE ADOPTION PART II This information is used to locate th birth record. If the child was previously adopted, please give the Name of Child at Birth Sex Birth Certificate No. (if known) Male Female Date of Birth (Mo/Day/Year) P lace of Birth (Hospital, City, State) Full Maiden Name of Mother Full Name of Father PART III MAILING ADDRESS AND TELEPHONE NUMBER Please include $30 .00 fee to process request, additional copies maybe obtained at the same time for $ 1 5 .00 each. Make check or money order payable to TENNESSEE VITAL RECORDS. Enter the address to which the birth certificate should be sent. NAME: ADDRESS: CITY, STATE, ZIP CODE: DAYTIME PHONE NUMBER: ( ) CERTIFICATION OF CLERK OF COURT State of County of Docket Number Date of Decree PART IV COURT SEAL TENNESSEE I hereby certify that there was a final decree of adoption entered by Court of this county on this the day, of , in the year , which adjudged t hat the child named in Part I is deemed to be the lawful child of the adoptive parents identified in Part I. Date SEND THIS FORM AND REQUIRED FEE TO: Tennessee Vital Records, Andrew Johnson Tower, 1st Floor, 710 James Robertson Parkway, Nashville, TN 37243 American LegalNet, Inc. www.FormsWorkFlow.com