Report To Vital Records Dss-5170 Form

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STATE OF NORTH CAROLINA
IN THE GENERAL COURT OF JUSTICE
DISTRICT COURT DIVISION
COUNTY
BEFORE THE CLERK
______ SP __________
_____________________________________________
Full name of petitioning parent
REPORT TO VITAL RECORDS
(
STEPPARENT ADOPTIONS)
FOR THE ADOPTION OF
_____________________________________________
(Full name by which adoptee is to be known)
Petition for adoption was filed on the _____________ day of __________________________________, ___________.
The undersigned Clerk of the Superior Court approved the adoption and granted a Decree of Adoption for said child to
the petitioner, _____________________________________________________________________________,
(Full name of petitioning stepparent)
on the ___________ day of ________________________, __________, and ordered that the said child shall be known
as _____________________________________________________________________________as provided by law.
First
Middle
Last
(Full name by which adoptee is to be known)
The court authorizes the ________________________________________ Vital Records Office to prepare a new birth
(State of child's birth)
certificate for said child which shall contain the full adoptive name of child, sex, race, date of birth, full name of
adoptive father or mother, as well as the biological parent who is the spouse of the adoptive parent, according to the
following information which is believed to be accurate. The new certificate shall contain no reference to the adoption of
the child and shall not refer to the adoptive parent in any way other than as the adoptee's parent.
This _______________ day of _______________________________________, ______________
____________________________________________________
Clerk Superior Court
(S E A L)
______________________________________________ County
DSS-5170 (Rev. 11/2014)
Child Welfare Services
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