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) (First) (Child's Birth Father) (Child's Birth Mother) (City) (First) (First) (Province) (Foreign Country) (First) (Middle) (Middle) (Middle) (Middle) (Foreign Country) (Month) (Last) (Year) (Year) (Male/Female) (Last) (Last) (Last) by the name of (Child's Birth Name)____________________________________________________________ was born to __________________________________________________________________________ father and _______________________________________________________________________________ mother in _______________________________________________________________________________________ The child described above was adopted in ______________ on the ___ day of _______________, __________ and is now to bear the new name of ____________________________________________________________. 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) (Last) ADOPTIVE FATHER -----Name ____________________________________ (First) (Middle) (Last) ADOPTIVE MOTHER-----Name ____________________________________ (First) (Middle) (Mother, Maiden Name) Birth Date _________________________________ Birth Place ________________________________ (City or Town, County, State, Country) Maiden Name ______________________________ Birth Date _________________________________ Birth Place ________________________________ (City or Town, County, State, Country) Present Mailing Address of Adoptive Parents: _________________________________________________________________________________________ (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 S E A L _________________, ________, Case No. _________________ (Month) (Year) Signature of Court Clerk ________________________________ Date Signed _________________________________________ State of _____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com