Alabama Adoption Report Form – Fill Out and Use This PDF

A L A B A M A

REPORT OF ADOPTI ON

INSTRUCTIONS: Parts I and II of this report must be completed by the petitioners, their attorney, or the Court. If the child was placed by a licensed child-placing agency or the State Department of Human Resources, information about 1) the natural parents, 2) place of birth of the child, and 3) birth certificate number may be omitted. This information is to be furnished to the State Registrar by the agency which placed the child.

Within ten (10) days after the final decree of adoption has been made, the Clerk of the Court shall make his certification in Part III, affix his official seal, and forward this report with the final decree of adoption to the State Registrar, Center for Health Statistics, P. O. Box 5625, Montgomery, Alabama 36103-5625. If the child was born in Alabama a new certificate listing the child’s new name and adoptive parents will be prepared. The fee to prepare this new birth certificate is $25.00 payable to the Alabama State Board of Health. This fee also includes one certified copy of the new certificate. If the adopted child was not born in Alabama, the State Registrar will forward the certified copy of the final decree of adoption and the report of adoption to the proper official in the state of birth. The fee to forward the final decree of adoption and report of adoption to the proper official in the state of birth is $10.00 payable to the Alabama State Board of Health. To obtain a certified copy of this birth certificate, contact the state of birth.

PART I

INFORMATION ABOUT CHILD (To Identify Original Birth Certificate)

NOTE: If the official birth certificate number is entered, the names of the father and mother may be omitted.

Full Name of Child at Birth

First

Middle

Last

Birth Certificate Number

Place of Birth City–Town or Location

State and Country of Birth

Date of Birth

Sex

Full Maiden Name of NATURAL Mother

First

Middle

Last

Full Name of LEGAL Father

First

Middle

Last

PART II

INFORMATION AFTER ADOPTION (FOR NEW BIRTH CERTIfiCATE)

Full Name of Child After Adoption

First

Middle

Last

FATHER — Full Name

First

Middle

Last

Father’s State of Birth (If not in U.S.A., name country)

Father’s Date of Birth

Father (Check One)

Adoptive

Natural

MOTHER — Full Maiden Name

First

Middle

Mother’s Legal Name First

Middle

Last

Last

Mother’s Date of Birth

Mother’s State of Birth (If not in U.S.A., name country)

Mother’s Usual Residence—State

Mother’s Residence — County

Mother’s Residence — City or Town and Zip Code

Mother’s Residence — Street Address (If rural, give location)

Mother’s Residence — Inside City

Mother (Check One)

Limits (Specify Yes or No)

Adoptive

Natural

Mailing Address of Adoptive Parents

Phone Number

Name and Full Address of Attorney Or Agency Representative

Phone Number

Title

PART III

CERTIFICATION OF CLERK OF COURT

Must be properly signed, dated and sealed.

For City, County

Name of Court

of

I hereby certify that the adoption as set forth above was made final in this Court by decree dated

and bearing No.		.
		Signature
	(Seal)	Title
		By

ADPH-HS-17/Rev. 10/2009