Dh Form 1905 - Certified Statement Of Final Order Of Affirmation Of Parental Status

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TYPE USING BLACK RIBBON

Florida Department of Health

Bureau of Vital Statistics

P. O. Box 210

Jacksonville, Florida 32231-0042

CERTIFIED STATEMENT OF FINAL ORDER OF AFFIRMATION OF PARENTAL STATUS

(Important - Read Information and Instructions on reverse side before completing.)

INFORMATION REGARDING ORIGINAL STATUS OF CHILD

Original Name of Child: ___________________________________________________________________________________________

(Middle)

(Last)

(First)

Sex: __________________________________ State File Number (If known): 109____________________________________________

Date of Birth: _________________________________Place of Birth: ______________________________________________________

(City)

(County)

(State)

Name of Father: __________________________________________________________________________ Race: _________________

(First)

(Last

(Middle)

Maiden Name of Mother: ___________________________________________________________________ Race: ________________

(First)

(Middle)

(Maiden Surname)

INFORMATION FOR A NEW CERTIFICATE OF BIRTH

Child's Name: __________________________________________________________________________________________________

(First)

(Last)

(MIddle)

FATHER

MOTHER

Name: _______________________________________

Name: _______________________________________________

(First,Middle,Last)

Date of Birth: _________________________________

Maiden Name: _________________________________________

Birth Place: ___________________________________

Date of Birth: _________________________________________

Race: ________________________________________

Birth Place: ___________________________________________

Social Security Number: _________________________

Race: ________________________________________________

Social Security Number: _________________________________

Residence Address of Father and Mother:

______________________________________________________________________________________________________________________________________________

Street and Number, Apt. No.

City, Town, or Location

County

State

Inside City Limits?

Zip Code

Mailing Address: _________________________________________________________________________________________________

(If same as residence, enter Zip Code only)

Legal Representative or Attorney:

Name: _______________________________________________________ Telephone Number: ________________________________

(Type)

Address: _______________________________________________________________________________________________________

Signature: ________________________________________________________________ Date: _______________________________

CERTIFICATE OF CLERK OF CIRCUIT COURT

On the _________ day of _____________________, 20_______, The Circuit Court of ________________________________ County,

Judge ____________________________________________________ presiding, issued a Final Order of Affirmation of Parental Status ordering the

Department of Health to issue a new birth certificate naming the commissioning couple identified in Section B above as the legal parents of the child identified in

Section B above and requiring the Department to seal the original birth certificate.

Signed and sealed by _______________________________________________________ Date: _____________________________

DH Form 1905, 10/2002