Fillable Certificate Of Adoption printable pdf download

STATE 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. PARENT

FIRST

MIDDLE

LAST

MAIDEN

10. PARENT

FIRST

MIDDLE

LAST

MAIDEN

SECTION 2

PLEASE 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

PARENT

14. TITLE OF PARENT

MOTHER

FATHER

PARENT

Adoptive

15. NAME OF PARENT

FIRST

MIDDLE

CURRENT LAST NAME

LAST NAME BEFORE MARRIAGE

16. DATE OF BIRTH

17. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)

18. PARENT’S SOCIAL SECURITY NO. (WILL NOT APPEAR ON THE BIRTH

ological

CERTIFICATE)

PARENT

19. TITLE OF PARENT

MOTHER

FATHER

PARENT

Adoptive

20. NAME OF PARENT

FIRST

MIDDLE

CURRENT LAST NAME

LAST NAME BEFORE MARRIAGE

21. DATE OF BIRTH

22. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)

23. PARENT”S SOCIAL SECURITY NO. (WILL NOT APPEAR ON THE BIRTH

Biological

CERTIFICATE)

PARENT(S) ADDRESS

24. STREET ADDRESS

CITY

COUNTY

STATE

ZIP

25. INSIDE CITY LIMITS?

AT THE TIME OF

Yes

CHILD’S BIRTH

PARENT(S)

26. STREET ADDRESS

CITY

STATE

ZIP

27. PARENT(S) TELEPHONE NUMBER:

CURRENT

ADDRESS

28. PARENT(S) EMAIL ADDRESS

29. SIGNATURE OF PARENT(S)

30.

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

31. BIOLOGICAL MOTHER

FIRST

MIDDLE

LAST (MAIDEN)

32. SSN

33. BIOLOGICAL MOTHER’S DATE OF BIRTH

34. BIOLOGICAL MOTHER’S PLACE OF BIRTH

CENTRAL

ADOPTION

35. BIOLOGICAL FATHER

FIRST

MIDDLE

LAST

36. SSN

REGISTRY

INFORMATION

37. BIOLOGICAL FATHER’S DATE OF BIRTH

38. BIOLOGICAL FATHER’S PLACE OF BIRTH

39. NAME OF ATTORNEY OF RECORD

40. ATTORNEY’S EMAIL ADDRESS

ATTORNEY

41. MAILING ADDRESS OF ATTORNEY

42. TELEPHONE NUMBER

PLACING

43. NAME OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR

AGENCY OR

MANAGING

44. MAILING ADDRESS OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR

45. TELEPHONE NUMBER

CONSERVATOR

SECTION 4

CERTIFICATION OF THE COURT

Please complete the child’s name as set forth in the Decree of Adoption

46. NAME OF THE CHILD AS SET FORTH IN THE ADOPTION DECREE:

FIRST

MIDDLE

LAST

47.

I HEREBY 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

VS-160 REV 8/2015

imprisonment and a fine of up to $10,000. (Health & Safety Code, §195,003)

Certificate Of Adoption

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