Form Vr 160 - Certificate Of Adoption Page 2
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2IllINOIs DEPARTmENT OF PUBlIC hEAlTh
Division Of Vital Records
925 E. Ridgely Ave.
Springfield, IL 62702-2737
CERTIFICATE OF ADOPTION
The certificate of adoption must be completed in its entirety. Failing to complete any portion of this form could result in the
document being returned to you without the adoption information being placed on the birth record. The fee for completing the
birth record of an Illinois born child is $15. This includes one certified copy of the new birth certificate. Additional copies ordered
at the same time are $2 each. Make check or money order payable to Illinois Department of Public Health or IDPH.
If you are submitting a certificate of adoption regarding a foreign born child, you must submit one additional document as
proof of the child’s place and date of birth. Records of foreign birth are $5 each.
If the adopted child was born in a state other than Illinois, this certificate of adoption will be forwarded to the state of birth.
Please type or print all information clearly. If you have additional questions, call the Division of Vital Records at
217-782-6553. Office hours are 10 a.m. to 3 p.m., Monday through Friday.
Child’s information at birth
Indicate the child’s full name at birth; month, day and year of birth; hospital, city, state and country (if other than the United
States) of birth. If the state file number of the birth record is known, indicate so. Provide the full names of the biological
mother/co-parent and father/co-parent. Indicate the sex of the child. If you are submitting an adoption regarding a foreign born
child, has the state issued a birth record for this child in connection with a prior adoption in Illinois? If you are submitting an
adoption regarding a foreign born child, has any state in the United States previously established a birth record for this child?
If so, in what state.
Child’s name after adoption
Indicate in the appropriate space the child’s first, middle and last name(s). Do not use white out or line through any part of the
new name. If alterations are made, a certified copy of the adoption decree will be required.
Parent’s information after adoption
Indicate if each parent is a co-parent, natural father, natural mother, adoptive father or adoptive mother, or if this is a single
parent adoption. Indicate if each parent is married or in a civil union. Give each parent’s first, middle and last name prior to first
marriage or civil union. Provide each month, day and year of birth; and the state or country (if other than the United States) of
birth for each. Each parent’s Social Security number is required; if either parent does not have a Social Security number,
please so indicate. Each parent must sign verifying his/her respective information.
Addresses
The address of the adoptive parent(s) at the time of the child’s birth is required. Provide the complete address including any
apartment number, city, state, ZIP code and county. If the biological mother/co-parent is also a parent after adoption, then her
address from the original birth record will be placed on the new birth record. The attorney’s complete address and telephone
number are required. The current address and telephone number of the adoptive parent(s) are also required. Indicate if a new
birth record is to be created and to whom it is to be sent.
Certification
This must be completed by the circuit clerk’s office in the county where the adoption was completed. The circuit clerk must
include his/her seal.
Printed by Authority of the State of Illinois
IOCI 12-106
VR 160
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