Report To Vital Records Dss-5170 Form Page 2
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1
2CHILD
Full name of child_________________________________________________________ Sex ______ Race ________
(As entered on original birth certificate)
Date of birth_____________________________________________________________________________________
(Month)
(Day)
(Year)
Place of birth____________________________________________________________________________________
(City or town)
(County)
(State or foreign country)
If birth occurred in a hospital or institution, give name and address _________________________________________
_______________________________________________________________________________________________
Full name of birth or
prior adoptive parent 1 _________________________________________________________Race ________ Sex ___
(First)
(Middle)
(Maiden)
(Married)
Full name of birth or
prior adoptive parent 2 _________________________________________________________Race ________ Sex ___
(First)
(Middle)
(Maiden)
(Married)
Full name of legal father ________________________________________________________Race ________Sex ___
ADOPTIVE STEPPARENT
Full name ________________________________________________________________ Race ___________ Sex___
(First)
(Middle)
(Maiden)
(Married)
Date of birth ___________________________ Place of birth ______________________________________________
(Month)
(Day)
(Year)
(County)
(State or foreign country)
BIOLOGICAL PARENT WHO IS SPOUSE OF STEPPARENT
Full name ________________________________________________________________ Race ___________ Sex___
(First)
(Middle)
(Maiden)
(Married)
Date of birth ___________________________ Place of birth ______________________________________________
(Month)
(Day)
(Year)
(County)
(State or foreign country)
Relationship to child _______________________________________________
Where did adoptive parent live at the time the Petition for Adoption was filed: _____________________________
_______________________________________________________________________ _____________________
(County)
Present address of adoptive parent: ______________________________________________________________
(address)
_______________________________________________________________________________________________
(City)
(State)
(Zip Code)
Telephone No. _________________________________
NOTE: One DSS-5170 is filled in by the Department of Social Services or licensed private child-placing agency for
presentation to the Clerk of Superior Court. When the Decree of Adoption is issued, the Clerk signs the DSS-5170 and
forwards it to the Division of Social Services, State Department of Health and Human Services, to be referred to the
Vital Records Office of the state in which the child was born.
DSS-5170 (Rev. 11/2014)
Child Welfare Services
Page 2 of 2
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