STATE OF COLORADO
REPORT OF ADOPTION
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1. CHILD’S ADOPTIVE NAME:
PARENTS: THE INFORMATION IN ITEMS 1-3 WILL APPEAR ON THE CHILD’S NEW BIRTH CERTIFICATE
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2. MOTHER’S NAME
PLEASE CHECK PARENT’S ROLE IF OTHER THAN MOTHER:
COPARENT
FATHER
state
country if not U.S.A.
2A. PARENT’S BIRTH DATE
2B. PARENT’S BIRTH PLACE:
3.FATHER’S
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FULL NAME:
PLEASE CHECK PARENT’S ROLE IF OTHER THAN FATHER:
COPARENT
MOTHER
state
country if not U.S.A
3A. PARENT’S BIRTH DATE
3B. PARENT’S BIRTH PLACE:
4. PARENTS’ CURRENT LEGAL NAMES:
street or box #
4A. PARENTS’ CURRENT MAILING ADDRESS:
city/town
state
zip
4B. DAYTIME PHONE #:
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5. TYPE OF ADOPTION (Check only one; see item C. on page 2):
TWO PARENT ADOPTION
STEP PARENT ADOPTION
SINGLE PARENT ADOPTION
SECOND PARENT ADOPTION
Attorney ID#:
ATTORNEY OR AGENCY (To be contacted for additional information if needed)
6.CONTACT NAME:
6A. FIRM OR AGENCY:
street or box #
city/town
state
zip
6B. ADDRESS:
6C. CONTACT PHONE #:
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6D. E-MAIL ADDRESS:
7. A NEW BIRTH CERTIFICATE WILL BE PREPARED UNLESS BOX IS CHECKED no
7A. WAS THE CHILD BORN IN A FOREIGN COUNTRY? yes
no
(If yes see item D. on page 2)
THIS INFORMATION IS NEEDED TO LOCATE AND SEAL THE CURRENT BIRTH CERTIFICATE
(see items E, F, and G on page 2)
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8.
8A. GENDER:
CHILD’S CURRENT NAME ON CERTIFICATE:
county
state
country if not U.S.A
8B. BIRTHDATE:
8C. BIRTHPLACE:
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9. MOTHER’S NAME PRIOR TO FIRST MARRIAGE
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10. FATHER’S NAME:
CERTIFICATION OF CLERK OF COURT
I hereby certify that the child identified above was adopted by the above named parents on the ________ day of ___________________, 20_____
and is now to bear the name of _____________________________________________________________________________________________
as set forth in the decree of Adoption in the District/Juvenile Court of ________________________________County, Colorado.
Case number _______________ Signature and seal of court _______________________________________________ Date _____/_____/_______
By _____________________________________________________ Deputy Clerk
Return form to:
Contact information:
Vital Records/Adoption Specialist
Vital Records Adoption Specialist
Colorado Department of Public Health and Environment
Phone: 303-692-2227
4300 Cherry Creek Drive South HSVR-VR-A1
E-mail: vital.records@state.co.us
Denver, CO 80246-1530
adoptreport.pmd
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rev. 07/08