UTAH DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND STATISTICS REPORT OF FOREIGN ADOPTEES PART 1. THIS INFORMATION MUST BE ENTERED AS ON THE ORIGINAL BIRTH CERTIFICATE Pursuant to Section 78-3-8.6 Utah Code the ___________________________ District Court has ordered the Utah State Registrar to file a Court Ordered Delayed Certificate of Birth for the following child: Born on ____________ day of __________________________, __________, a ___________________ (Child's Date of Birth) (Month) (Year) (Male/Female) by the name of (Child's Birth Name) _______________________________________________________ SEE INSTRUCTIONS, FEE AND ADDRESS ON REVERSE SIDE. (First) (Middle) (Last) was born to _____________________________________________________________________ father (Child's Birth Father) (First) (Middle) (Last) and __________________________________________________________________________ mother (Child's Birth Mother) (First) (Middle) (Mother, Maiden Name) in __________________________________________________________________________________ (City) (Province) (Foreign Country) The child described above was adopted in __________________on the __day of ____________, _____ (Foreign Country) (Month) (Year) and is now to bear the new name of_______________________________________________________. (First) (Middle) (Last) PART 2. INFORMATION FROM ADOPTIVE PARENTS All information requested below MUST be provided or a Court Ordered Delayed Birth Certificate cannot be completed for filing. CHILD'S NEW NAME AFTER ADOPTION __________________________________________________ (First) (Middle) ADOPTIVE FATHER (Last) ADOPTIVE MOTHER Name ___________________________________ Name ____________________________________ (First) (Middle) (Last) (First) (Middle) (Mother, Maiden Name) Birth Date _______________________________ Maiden Name______________________________ Birthplace________________________________ Birth Date ________________________________ (City or Town, County, State, Country) Present Mailing Address of Adoptive Parents: Birthplace ________________________________ (City or Town, County, State, Country) ___________________________________________________________________________________ (Street and Number of Residence) (City/Town/Community) (County) (State) (Zip Code) PART 3. CERTIFICATION OF DISTRICT COURT CLERK OR COUNTY CLERK (Please DO NOT use all capital letters) CERTIFICATION OF COURT CLERK (INK SEALS MUST BE IN COLOR) I hereby certify that an Order of Registration of Foreign Adoption for the above named child was entered on this _________ day of ___________________, _________, Case No. ______________ S (Month) E (Year) Signature of Court Clerk _________________________________ A Date Signed ___________________________________________ L State of _______________________________________________ OVRS Rev. 11/05 American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS Prompt submission of the report when properly completed will expedite the filing of a Court Ordered Delayed birth certificate. COURT: Complete sections 1, 2 and 3 of this form. Please give full information about the adoptive parents. CLERK OF THE DISTRICT COURT: It is the duty of the Clerk of the District Court to forward this form, properly completed to the Office of Vital Records, 288 North 1460 West, P O Box 141012, Salt Lake City, Utah 84114-1012. Do not mail a check with this form without reading the REQUIREMENT for IDENTIFICATION below. GENERAL INFORMATION Upon receipt of the certified Report of Foreign Adoptees from the Clerk of the Court and the required fee (see below), the State Registrar will prepare a Court Ordered Delayed Birth Certificate with the new name of the child as shown on the Report of Foreign Adoptees. The Report of Foreign Adoptees, and other related information will be placed in a sealed file and therefore may not be referred to except upon the order of a Utah Court. UTAH CODE 78-30-8.6. Adoption order from foreign country. (1) Except as otherwise provided by federal law, an adoption order rendered to a resident of this state that is made by a foreign country shall be recognized by the courts of this state and enforced as if the order were rendered by a court in this state. (2) A person who adopts a child in a foreign country may register the order in this state. A petition for registration of a foreign adoption order may be combined with a petition for a name change. If the court finds that the foreign adoption order meets the requirements of Subsection (1), the court shall order the state registrar to: (a) file the order pursuant to Section 78-30-9; and (b) file a certificate of birth for the child pursuant to Section 26-2-28. (3) If a clerk of the court is unable to establish the fact, time, and place of birth from the documentation provided, a person holding a direct, tangible, and legitimate interest as described in Subsection 26-2-22(2)(a) or (b) may petition for a court order establishing the fact, time, and place of a birth pursuant to Subsection 26-2-15(1). Enacted by Chapter 56, 2004 General Session TO OBTAIN A SUPPLY OF THESE FORMS: Write to the Office of Vital Records, 288 North 1460 West, P O Box 141012, Salt Lake City, Utah 84114-1012. If you have questions, please call (801) 538-6363. NECESSARY INFORMATION COURT ORDERED DELAYED BIRTH CERTIFICATE FOR FOREIGN BORN CHILDREN: 1. Report of Foreign Adoptees, or 2. If a clerk of the court is unable to establish the fact, time and place of birth from the documentation provided, a person holding a direct, tangible, and legitimate interest as described in Subsection 26-2-22(2)(a) or (b) may petition for a court order establishing the fact, time and place of a birth pursuant to Subsection 26-2-15(1). 3. Fee of $40.00. Additional copies on the same day are $8.00 each. NOTE: State law requires a $40.00 fee for filing new birth certificates. A copy of the new certificate cannot be provided prior to payment of this fee. IDENTIFICATION IS REQUIRED from the parent requesting the new birth certificate. Mailed requests must include an enlarged and easily identifiable photocopy of the back and front of your identification such as a valid driver license. If no proofs are enclosed, your request for the new birth certificate will be returned. American LegalNet, Inc. www.USCourtForms.com