Application To Release An Original Birth Certificate By Mutual Consent
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1Colorado Department of Public Health and Evironment
Application To Release An Original Birth Certificate By Mutual Consent
Upon the mutual consent of 2 or 3 reuinted parties, the original birth certificate can be released to the eligible parties. Eligible parties
per Colorado Revised Statutes 19-5-305 are: adult adoptee, birth mother and birth father. Your request will be processed within 30 working days.
Please submit a completed notarized consent form along with $37.75, and copies of ID's of the adoptee and the living biological parent(s)
(the notarized signatures of the adult adoptee and birth parent(s) are required on one form) to:
Vital Records
Adoption Specialist
4300 Cherry Creek Drive South
Denver, CO 80246-1530.
Name ________________________________________________ Relationship _________________________________
Address ___________________________________________________________ City ___________________________
State __________________________ Zip Code ______________ Daytime Phone number _______-_______-_________
_________________________________________________________________
Subscribed and sworn to before me this
Adoptee’s name on original birth certificate
_________ day of _____________ 20 ___
_________________________________________________________________
Adoptee’s name that appears on the adoptive birth certificate
__________________________________
Notary Public
________________________
___________________________, Colorado
Adoptee=s date of birth
Adoptee’s place of birth
My commission expires _______________
_________________________________________________________________
In the county of ____________________
Adoptee’s signature
State of ___________________________
_________________________________________________________________
Subscribed and sworn to before me this
Biological mother’s name on adoptee’s original birth certificate
_________ day of ____________ 20 ___
_________________________________________________________________
Biological mother’s current name
__________________________________
Notary Public
________________________
__________________________________
Date of birth
Place of birth
y commission expires ______________
M
_________________________________________________________________
In the county of ____________________
Birth mother's signature
State of ___________________________
_________________________________________________________________
Subscribed and sworn to before me this
Birth father’s name, as it appears on the adoptee’s original birth certificate
_________ day of _____________ 20 ___
_________________________________________________________________
Birth father’s current name
__________________________________
Notary Public
_________________________
_________________________________
Date of birth
Place of birth
y commission expires _______________
M
_________________________________________________________________
In the county of ____________________
Birth father's signature
State of ___________________________
Per Statute 19-5-305: If any of the persons on the original birth certificate are deceased, submit a certified copy of their death
certificate in lieu of the signature. If one of the birth parents is deceased and the other birth parent is living but is nonconsenting,
then access to the records shall be permitted without the name of the nonconsenting birth parent.
Form-VR06 Rev. 12/2014
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