Adoption Report Form

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Center for Health Statistics
ADOPTION REPORT
THIS IS A PERMANENT RECORD — PLEASE TYPE OR PRINT ONLY
PLEASE FURNISH INFORMATION AS TAKEN FROM ORIGINAL BIRTH RECORD.
PART I
THIS INFORMATION IS NECESSARY TO LOCATE THE ORIGINAL BIRTH CERTIFICATE.
1. Name of child — First
Middle name
Last name
1A. Sex
FACTS OF
2. Date of birth
3. Name of physician, if known
BIRTH
4A. Place of birth — Hospital
4B. City
4C. State (if not in U.S.A., name country)
5. Name of mother — First
Middle name
Maiden name
Last name
NATURAL
6. Name of father — First
Middle name
Last name
PARENTS’
DATA
7. U.S. citizenship — Was natural mother a U.S. citizen when child was born?
8. U.S. citizenship — Was natural father a U.S. citizen when child was born?
 No
 Yes
 No
 Yes
9. Was the child listed above previously adopted in the united states?
10. State/County of adoption:
PRIOR
 No
 Yes
ADOPTION
If yes, please complete item #10.
PLEASE ENTER INFORMATION BELOW AS IT IS TO APPEAR ON THE NEW BIRTH RECORD.
PART II
If any information is left blank, it will be blank on the birth certificate.
All information requested below MUST be provided or a new birth certificate cannot be completed for filing.
11. Current legal name of mother/parent A — First
Middle name
Last name
MOTHER
11A. Legal/Maiden name at birth of mother/parent A — First
Middle name
Last name at mother’s birth/maiden name
(check one)
12. Date of birth
13. State of birth (if not in U.S.A., name country)
14. Social Security Number
Adoptive
Natural
15. Mother’s residence at time of child’s birth
15A. Residence street address
Parent A
15B. State (if not in U.S.A., name country)
15C. County
15D. City
15E. Zip code
15F. Inside city limits?
 No
 Yes
16. Name of father/parent B — First
Middle name
Last name
FATHER
(check one)
17. Date of birth
18. State of birth (if not in U.S.A., name country)
19. Social Security Number
Adoptive
Natural
20A. If adoptive person is an adult, is new birth record to be issued?
20B. Is this a step-parent adoption?
20C. Is this a single-parent adoption?
Parent B
 No
 Yes
 No
 Yes
 No
 Yes
21. Agency or person through which child was obtained
AGENCY
22A. Name (print or type)
22B. Mailing address
Zip code
22C. Telephone
ATTORNEY
ADOPTIVE
23A. Current mailing address
23B. Telephone
PARENTS
The clerk of the court should require that as much of the information as is available in parts I and II
PART III
be completed before certification is made and the report mailed to the registrar of vital statistics.
24. I hereby certify that an adoption decree was filed on the
25. Adopted name of child as set forth in decree
First name
Middle name
Last name
Day of
20
Case no.
26. Signature of
Clerk of court
County of
COURT SEAL:
The $35 fee for amendment of Oregon birth certificate may be submitted with this form.
The $35 fee does not include a certified copy of the new certificate.
One short-form certificate is $25.
One full-image, long-form certificate is $30 (available for 1903-2007).
Mail to: Center for Health Statistics, P.O. Box 14050, Portland, Oregon 97293-0050
45-24 (01/16)

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