Confidential Report Form Of City And Town Clerk Relative To An Adoption

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STATE OF NEW HAMPSHIRE
Department of State
Division of Vital Records Administration
CONFIDENTIAL Report of City and Town Clerk Relative to an Adoption
TYPE OR PRINT ONLY
I.
CHILD
1. CHILD’S (First)
(Middle)
(Last)
2.
DATE
(Month) (Day) (Year)
3. SEX
NAME
OF
BIRTH
CHILD
4. LOCATION
(City/Town)
(County)
(State/Country)
INFORMATION
OF
BIRTH
AS IT APPEARS
BEFORE
5. RACE
WHITE
BLACK
CHINESE/JAPANESE
6. ANCESTRY? (English, French,
ADOPTION
OTHER ASIAN/PACIFIC ISLAND
Puerto Rican, etc.) Specify
AMERICAN INDIAN/ALASKAN NATIVE
OTHER, SPECIFY
7. SIBLINGS IN SUBSTITUTE
8. MEMBER SIBLING GROUP ADOPTED
9. PREVIOUS ADOPTIVE PLACEMENT?
CARE?
TOGETHER?
YES
NO
YES
NO
YES
NO
10. SPECIAL
Yes
If Yes, Primary Basis:
Age
Racial/Ethnic
Member Sibling Group
Medical/Other Disability
NEEDS
No
Other, Specify
CHILD
If Medical/Other, Check All That Apply
Blind/Visually Impaired
Deaf/Hard of Hearing
Physically Disabled
Mental Retardation
Emotionally Disturbed
Learning Disability
Medical Condition
Other, Specify:
11. DATE OF
(Month) (Day) (Year)
12. AUSPICES OF
PUBLIC AGENCY
INDEPENDENT PERSON
ADOPTIVE
ADOPTION
TRIBAL AGENCY
PRIVATE AGENCY
PLACEMENT
OTHER, SPECIFY
13. LOCATION OF AGENCY/PERSON (State/Country)
II.
SUPPORT
14. ADOPTION SUBSIDY
YES
NO
COMPLETE IF
15. SOURCES OF FINANCIAL SUPPORT (CHECK ALL THAT APPLY)
STATE/FEDERAL
TITLE IV-MONTHLY
TITLE IV-E NON-RECURRING
STATE ONLY TITLE XVI (SSI)
SUPPORT FOR
TITLES XIX/XX WITH NO PAYMENT
NONE OF ABOVE, PARENTS ONLY
CHILD
OTHER, SPECIFY
III.
BIOLOGICAL
16. FATHER’S NAME (First)
(Middle)
(Last)
17. DATE
(Month) (Day) (Year)
FATHER
(If stated on
OF
birth certificate)
BIRTH
18. WAS TERMINATION OF PARENTAL RIGHT
(Month)
(Day)
(Year)
19. ANCESTRY? (English, French,
Puerto Rican, etc.) Specify
VOLUNTARY – Date of Surrender/Consent
NON-VOLUNTARY – Date of Termination of Rights
NOT APPLICABLE
20. RACE
WHITE
BLACK
CHINESE/JAPANESE
OTHER ASIAN/PACIFIC ISLANDER
AMERICAN INDIAN/ALASKAN NATIVE
UNKNOWN
OTHER, SPECIFY
21. MARITAL STATUS
MARRIED
DIVORCED
CIVIL UNION
SEPARATED
SINGLE
WIDOWER
CIVIL UNION DISSOLUTION
IV.
BIOLOGICAL
22. MOTHER’S MAIDEN SURNAME
23. DATE
(Month) (Day) (Year)
24. MOTHER MARRIED
MOTHER
OF
AT BIRTH OF CHILD?
BIRTH
YES
NO
25. WAS TERMINATION OF PARENTAL RIGHT
(Month)
(Day)
(Year)
26. ANCESTRY? (English, French,
Puerto Rican, etc.) Specify
VOLUNTARY – Date of Surrender/Consent
NON-VOLUNTARY – Date of Termination of Rights
NOT APPLICABLE
27. RACE
WHITE
BLACK
CHINESE/JAPANESE
OTHER ASIAN/PACIFIC ISLANDER
AMERICAN INDIAN/ALASKAN NATIVE
UNKNOWN
OTHER, SPECIFY
28. MARITAL STATUS
MARRIED
DIVORCED
CIVIL UNION
SEPARATED
SINGLE
WIDOWER
CIVIL UNION DISSOLUTION
(Continued on Back)
PAGE 1
V.S.-37
03/08

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