Certificate Of Adoption Template (Page 2 of 2) in pdf

CERTIFICATE OF ADOPTION

INSTRUCTIONS

These instructions are designed to assist you in the proper completion of the Certificate of Adoption. Should you have any questions,

please contact our office toll free at 888-963-7111 for assistance. PLEASE TYPE OR PRINT LEGIBLY.

SECTION 1

The information in this section relates to the child’s information currently on file in the Vital Statistics Office. Enter the name of the

child prior to adoption in item 1. This information must be supplied to enable us to locate the adoptee’s current certificate of birth.

SECTION 2

Item #11 If this is a step-parent adoption, the information concerning the natural parent MUST also be furnished.

Item # 12 If this is a single parent adoption, please complete the appropriate information regarding adopting parent.

A step-parent adoption is not a single-parent adoption.

Item #13 If a NEW certificate is to be prepared, mark “YES”.

Items #14 through #27 this information relates to the adoptive parents. Some of this information will be transferred to the NEW

certificate of birth.

Item #28 should be completed to indicate if the Attorney, Parent(s), or District Clerk will receive the new birth certificate and provide

the current mailing address of the recipient.

SECTION 3

Items #29 through #36 are for the Central Adoption Registry. Please provide the requested information obtained on the biological

parents at the time of the adoption and/or termination of parental rights.

Items #37 through #40 Enter the name, mailing address, email address and telephone number of the attorney of record.

Items #41 through #43 Enter the information relating to the child placing agency or managing conservator.

SECTION 4

Items #44 through #45, should be completed by the Clerk of the Court. This section MUST be completed to show the child’s name

after adoption as shown in the final decree of adoption. If Section 4 is not completed by the clerk of the court granting the adoption, a

CERTIFIED COPY of the final decree of adoption MUST be attached to the certificate of adoption form and will be retained by our

office.

EXPLANATION OF FEES:

FOR CHILDREN BORN IN TEXAS OR A FOREIGN COUNTRY, THE FEE TO FILE A NEW BIRTH CERTIFICATE BASED ON

ADOPTION IS $47.00. THE $47.00 FEE INCLUDES THE REQUIRED $25.00 FEE TO FILE THE ADOPTION AND THE $22.00

FEE TO ISSUE ONE CERTIFIED COPY OF THE NEW BIRTH CERTIFICATE. (ADDITIONAL CERTIFIED COPIES ARE $22.00

EACH)

THE $15.00 CENTRAL ADOPTION REGISTRY (CAR) FEE IS REQUIRED ON EACH ADOPTION DECREE GRANTED IN TEXAS.

IF THE CHILD WAS BORN IN ANOTHER STATE AND THE ADOPTION WAS GRANTED IN TEXAS, ONLY THE $15.00 CAR FEE

IS REQUIRED.

FOR ADOPTIONS GRANTED IN OTHER US STATES OR TERRITORIES THE CENTRAL ADOPTION REGISTRY FEE OF $15.00

IS NOT REQUIRED.

A TOTAL FEE OF $62.00 MAY BE SUBMITTED IN ONE PAYMENT MADE PAYABLE TO TEXAS VITAL STATISTICS.

MAIL THE PROPERLY COMPLETED CERTIFICATE OF ADOPTION WITH THE

APPROPRIATE FEES TO:

VITAL STATISTICS UNIT

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

PO BOX 12040

AUSTIN TX 78711-2040

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

Certificate Of Adoption Template Page 2

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