Certificate Of Adoption Template
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1
2STATE OF TEXAS
CERTIFICATE OF ADOPTION
THIS IS A PERMANENT RECORD – PLEASE TYPE OR PRINT ONLY
SECTION 1
PLEASE FURNISH THE BIRTH CERTIFICATE INFORMATION CURRENTLY ON
FILE IN THE VITAL STATISTICS OFFICE.
THIS INFORMATION IS NECESSARY TO LOCATE THE BIRTH CERTIFICATE
1. NAME OF CHILD (BEFORE THIS ADOPTION)
FIRST
MIDDLE
LAST
2. DATE OF BIRTH (mm/dd/yyyy)
3. SEX
ORIGINAL
4. TIME OF BIRTH
5. NAME OF HOSPITAL
6. CITY
7. COUNTY
8. STATE OR FOREIGN COUNTRY
BIRTH
INFORMATION
9. NATURAL MOTHER
FIRST
MIDDLE
MAIDEN
10. NATURAL FATHER
FIRST
MIDDLE
LAST
PL
SECTION 2
EASE ENTER THE INFORMATION AS IT IS TO APPEAR ON THE NEW BIRTH RECORD.
All information below MUST be provided or a new birth certificate cannot be completed.
Single-Parent Adoption – Complete Only The Appropriate Information Regarding The Adopting Parent
11. Is This a Step-Parent Adoption?
12. Is This a Single Parent Adoption?
13.
Do You Want The Birth Record Changed Based on the Adoption Decree?
Yes
No
Yes
No
Yes
No
MOTHER
14. NAME OF MOTHER
FIRST
MIDDLE
CURRENT LAST NAME
MAIDEN LAST NAME
Adoptive
17. MOTHER’S SOCIAL SECURITY NUMBER (WILL NOT APPEAR ON THE
15. DATE OF BIRTH
16. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
BIRTH CERTIFICATE)
Natural
FATHER
18. NAME OF FATHER
FIRST
MIDDLE
LAST
Adoptive
21. FATHER’S SOCIAL SECURITY NUMBER (WILL NOT APPEAR ON THE
19. DATE OF BIRTH
20. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
BIRTH CERTIFICATE)
Natural
PARENT(S) ADDRESS
22. STREET ADDRESS
CITY
COUNTY
STATE
ZIP
23. INSIDE CITY LIMITS?
AT THE TIME OF
Yes
No
CHILD’S BIRTH
PARENT(S)
24. STREET ADDRESS
CITY
STATE
ZIP
25. PARENT(S) TELEPHONE NUMBER:
CURRENT
ADDRESS
26. PARENT(S) EMAIL ADDRESS
27. SIGNATURE OF PARENT(S)
28:
MAILING ADDRESS
CITY
STATE
ZIP
MAIL BIRTH
Attorney
Parent(s)
Clerk’s Office
CERTIFICATE TO:
SECTION 3
PLEASE PROVIDE THE INFORMATION BELOW FOR THE CENTRAL ADOPTION REGISTRY
29. NATURAL MOTHER
FIRST
MIDDLE
LAST (MAIDEN)
30. SSN
31. NATURAL MOTHER’S DATE OF BIRTH
32. NATURAL MOTHER’S PLACE OF BIRTH
CENTRAL
ADOPTION
REGISTRY
33. NATURAL FATHER
FIRST
MIDDLE
LAST
34. SSN
INFORMATION
35. NATURAL FATHER’S DATE OF BIRTH
36. NATURAL FATHER’S PLACE OF BIRTH
38. ATTORNEY’S EMAIL ADDRESS
37. NAME OF ATTORNEY OF RECORD
ATTORNEY
39 MAILING ADDRESS OF ATTORNEY
40. TELEPHONE NUMBER
PLACING
41. NAME OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR
AGENCY OR
MANAGING
42. MAILING ADDRESS OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR
43. TELEPHONE NUMBER
CONSERVATOR
SECTION 4
CERTIFICATION OF THE COURT
Please complete the child’s name as set forth in the Decree of Adoption
44. NAME OF THE CHILD AS SET FORTH IN THE ADOPTION DECREE:
FIRST
MIDDLE
LAST
45. I HEARBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AS STATED IN THE DECREE OF ADOPTION WHICH WAS GRANTED
ON _______________DAY OF________________________,___________IN THE____________________COURT OF ________________
COUNTY, TEXAS IN CAUSE #__________________________.
_____________________________________
DISTRICT CLERK’S SIGNATURE
Warning: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing a form which contains a false statement is 2 to 10 years
imprisonment and a fine of up to $10,000. (Health & Safety Code, §195,003)
VS-160 REV 01/2014
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