Massachusetts Form R 109 PDF Details

The Massachusetts R 109 form serves as a pivotal document for individuals seeking access to a non-certified record of birth prior to adoption. Managed by the Massachusetts Department of Public Health Registry of Vital Records and Statistics, this form caters to a select group of individuals, including adoptees, adoptive parents, adult children of deceased adoptees, and legal guardians of a deceased adoptee's child. It outlines a structured process for applying either in person or by mail, with specific fees set for each method. Completion of the form requires meticulous attention to details such as the adoptee's information, the requester's details, and an affidavit of application to be notarized if submitting by mail. It further necessitates the provision of various identifying and supplemental documents, ensuring applicants comply with the state's legal requirements. Additionally, this form highlights the eligibility criteria defined by state law, allowing access to pre-adoption birth records without needing a judicial court order under certain conditions. Thus, the Massachusetts R 109 form is a critical resource for eligible parties aiming to uncover information about an adoptee’s origins prior to their adoption.

QuestionAnswer
Form NameMassachusetts Form R 109
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmassachusetts record adoption, massachusetts application adoption, massachusetts r109, massachusetts birth form

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MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH REGISTRY OF VITAL RECORDS AND STATISTICS 150 MT. VERNON STREET, 1st Floor

DORCHESTER, MA 02125-3105

APPLICATION FOR A NON-CERTIFIED RECORD OF BIRTH PRIOR TO ADOPTION

(Please print legibly.)

RVRS USE ONLY Rec’d_____________

#_________________

Cert #_____________

Completed_________

Initials_____________

Please fill out and return this form to the address above. If you are requesting a record by mail, make your check or money order payable to the Commonwealth of Massachusetts and include $32.00 for each copy requested. DO NOT SEND CASH THROUGH THE MAIL. Records requested in-person at the Registry counter are $20.00 per copy. Checks, money orders, and cash are accepted at the counter. Credit/debit cards are not accepted. See additional instructions on the reverse of this form.

SUBJECT OF THE RECORD (ADOPTEE)

Number

 

of Copies:

 

 

Full Name on Current Birth Record (name at adoption) (First, Middle, Last)

Date of Birth* (Month, Day, Year)

Full Name of Adoptive Mother/Parent (First, Middle, Last)

Maiden surname of Adoptive Mother

Full Name of Adoptive Father/Parent (First, Middle, Last)

City/Town of Birth

Name on Pre-Adoption Birth Record (name at birth), if known

PERSON MAKING REQUEST

Full Legal Name (Current Name) (First, Middle, Last)

Relationship to Adoptee

 

Self

Adoptive parent

 

Adult child of deceased adoptee

 

Legal guardian of child (under 18

 

years) of a deceased adoptee

Mailing Address

Telephone number(s)

(Street/PO Box/Apt. #)

 

 

(City/Town, State, Zip)

 

 

 

 

 

AFFIDAVIT OF APPLICANT (If you are applying by mail, you must sign and date this section in the presence of a notary.) WARNING: Providing false information under this oath or affirmation is punishable by fine and imprisonment under M.G.L. c.268 §6.

I hereby swear or affirm under the penalties of perjury that the information on this application is true to the best of my knowledge and belief.

________________________________________________________ _______________________

Signature

Date

On this _______________ day of ___________________________, ____________ before me, the undersigned notary public, personally appeared

____________________________________________________________________ who proved to me through satisfactory evidence of identification,

which were __________________________________________________________, to be the person whose name is signed on this document and

who swore or affirmed to me that the contents of the document were truthful and accurate to the best of their knowledge and belief and that they signed

this form voluntarily for its stated purpose.

Notary Public _____________________________________________________

 

My Commission Expires: ____________________________________________

IDENTIFICATION AND SUPPLEMENTAL DOCUMENTATION (see additional information on the reverse of this form)

IDENTIFICATION If you are applying in-person you will need to show one of the following identification documents. If you are applying by mail, you must enclose a clear, legible, photocopy of the identification document. Alternative identification documents require prior approval by RVRS.

Valid, non-expired, driver’s license

Valid, non-expired, identification card

Valid, non-expired, passport

 

issued by a department of motor vehicles

 

DOCUMENTATION If you are applying in-person and additional documentation is required (see reverse of form), you must provide an original certified copy for inspection. If you are applying by mail and additional documentation is required, you must send an original certified copy that will be returned to you with completion of your order.

Proof of name change:

Proof of death:

Proof of relationship:

Certified copy of a marriage certificate

Certified copy of death certificate

Certified copy of your birth certificate

Certified copy of a legal change of name decree

 

Certified copy of legal guardianship

Other (specify):

 

 

*Records on file at the Registry of Vital Records and Statistics date back to 1926. Earlier records are housed at the State Archives.

Form R-109 (04/2016)

APPLICATION FOR RECORD OF BIRTH PRIOR TO ADOPTION

Application Instructions

Who May Apply?

Beginning December 5, 2007, certain individuals specified by state law may apply for a copy of an initial birth record established prior to an adoption (without first obtaining a judicial court order):

Adoptees who were born in Massachusetts on or before July 14, 1974.

An adult child (18 years or older) of a deceased parent who was an adoptee born in Massachusetts on or before July 14, 1974.

The parent or guardian of a child (under 18 years of age) whose deceased parent was an adoptee born in Massachusetts on or before July 14, 1974.

Beginning January 1, 2008, the following additional individuals specified by state law may also apply:

The adoptive parent of a child (under 18 years of age) born in Massachusetts on or after January 1, 2008.

Beginning January 1, 2026, the following additional individuals specified by state law may also apply:

An adult adoptee (18 years or older) who was born in Massachusetts on or after January 1, 2008. Submit your application by mail or in person

If you are applying by mail, you must include copies of all identification and documentation listed below, and your signature must be notarized. The fee for applying by mail is $32.00. Please do not send cash by mail. Checks and money orders should be made payable to the “Commonwealth of Massachusetts.” Credit and debit cards are not accepted. RVRS will also accept applications by walk-in customers. If you are applying in person, your application will be reviewed for completeness, your identification and documentation will be checked, payment will be taken, and the application will be processed in the order it was received. The fee for applying in person is $20.00.

What you will receive if, after processing of your application, RVRS locates your birth record prior to adoption

You will receive a copy of the birth record that was registered with RVRS prior to adoption that lists among other items, the legal parent or parents listed on the record at the time of birth. In a very few cases, there may have been an amendment prior to the adoption, for which you will receive the initial record and any relevant amendments (e.g., paternity establishment).

The copy will be made on security paper to deter potential fraudulent use, and will contain, the following statement mandated by state law: “The contents of this birth record are being released under section 2B of chapter 46 of the Massachusetts General Laws or under a court order. This record was amended by adoption. This is not a certified copy of a birth record.”

Refunds

If the application can not be processed for any reason, it will be returned to you with a refund.

If you do not sign for the record that is sent to you by certified mail, and the record is returned to RVRS, you will NOT be issued a refund, as the cost has already been incurred.

Identification Requirements

1.If you are applying for your OWN record:

A current government-issued photo ID. (For applications by mail, attach a photocopy of the ID):

Current, not expired, driver’s license, or

Current, not expired, other ID issued by your state’s department of motor vehicles, or

Current, not expired, passport

If you cannot provide one of the identification items listed above, please call RVRS to be certain the ID you plan to provide is adequate.

Documentation of a change of name. If the name on your ID is different from your name at the time of your adoption, you must provide documentation that will prove you are the person listed on the birth record. (For applications by mail, attach an original certified copy of the requested documentation. Your original documents will be returned to you with the completed order). For example:

If your ID shows a married name, provide a certified copy of your marriage certificate that shows your name as it appears on your current (adoptive) birth certificate and your name after marriage as it appears on your ID.

If your ID reflects a legal change of name, provide a certified copy of your legal change of name decree that shows your name as it appears on your current (adoptive) birth certificate and your legal name as decreed by a court and as appears on your ID.

2.If you are applying for YOUR PARENT’S record:

You must provide the identification listed above in numbered section 1, AND also show or provide:

A certified copy of your parent’s death record. If you are applying by mail, attach an original certified copy of your parent’s death record.

A certified copy of your birth record that shows you are the decedent’s child. If you are applying by mail, attach an original certified copy of your parent’s death record.

Documentation of any change of name not reflected on the death certificate. If your parent’s death certificate does not contain in some format a reference to his or her name at the time of adoption (e.g, maiden name, or name at birth or adoption), then you will need to provide evidence of the change of name as described above in numbered section 1.

3.If you are applying for YOUR ADOPTED CHILD’S record (beginning January 1, 2008):

You must provide the identification listed above in numbered section 1.

For all requests submitted by mail, notarization is required:

For requests by mail only, sign and date your application in the presence of a notary who will certify that your signature is authentic.

Questions

Contact the Registry of Vital Records and Statistics at (617) 740-2600 or by email at vital.recordsrequest@state.ma.us.

Form R-109 (11/2007)

How to Edit Massachusetts Form R 109 Online for Free

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Find out how to complete massachusetts birth form step 1

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