Confidential Report Form Of City And Town Clerk Relative To An Adoption Page 2

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V. ADOPTIVE
29. MOTHER’s/ (First)
(Middle)
(Last)
30. MAIDEN NAME
31. DATE
(Month) (Day) (Year)
MOTHER/
PARENT A’s
(If applicable)
OF
PARENT A
NAME
BIRTH
32. RACE
WHITE
BLACK
CHINESE/JAPANESE
33. ANCESTRY? (English, French,
OTHER ASIAN/PACIFIC ISLAND
Puerto Rican, etc.) Specify
AMERICAN INDIAN/ALASKAN NATIVE
OTHER, SPECIFY
34. STATE OF BIRTH
35. RESIDENCE
(Street Address)
(City/Town)
(County)
(State)
AT TIME OF
CHILD’S BIRTH:
36. MARITAL STATUS
37. RELATIONSHIP TO CHILD
MARRIED
DIVORCED
CIVIL UNION
STEP PARENT
SEPARATED
SINGLE
WIDOWER
FOSTER PARENT
BIOLOGICAL MOTHER
CIVIL UNION DISSOLUTION
RELATIVE
CO-PARENT
VI. ADOPTIVE
38. FATHER’s/
(First)
(Middle)
(Last)
39. MAIDEN NAME
40. DATE
(Month) (Day) (Year)
FATHER/
(If applicable)
PARENT A’s
OF
NAME
BIRTH
PARENT B
41. RACE
WHITE
BLACK
CHINESE/JAPANESE
42. ANCESTRY? (English, French,
OTHER ASIAN/PACIFIC ISLAND
Puerto Rican, etc.) Specify
AMERICAN INDIAN/ALASKAN NATIVE
OTHER, SPECIFY
43. STATE OF BIRTH
44. RESIDENCE
(Street Address)
(City/Town)
(County)
(State)
AT TIME OF
CHILD’S BIRTH:
45. MARITAL STATUS
46. RELATIONSHIP TO CHILD
MARRIED
DIVORCED
CIVIL UNION
STEP PARENT
SEPARATED
SINGLE
WIDOWER
FOSTER PARENT
BIOLOGICAL FATHER
CIVIL UNION DISSOLUTION
RELATIVE
CO-PARENT
VII.
INCOME
47. FAMILY INCOME OF
Under $25,000
$25,000 – $34,999
ADOPTIVE PARENTS
$35,000 – $44,999
$45,000 – $54,999
$55,000 and over
VIII. ADOPTIVE
48.
WE DO NOT WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION.
PARENTS
WE WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION.
A NEW BIRTH CERTIFICATE IS PREPARED FOR THE ADOPTEE AFTER THE ADOPTION IS GRANTED. WE REQUEST THAT THE
AMENDED BIRTH RECORD BE PREPARED TO SHOW THE PARENT’S NAMES AND THE NAME OF THE ADOPTEE AS FOLLOWS:
49. MOTHER’S/PARENT A’s NAME
(First)
(Middle)
(Last)
50. FATHER’S/PARENT B’s NAME
(First)
(Middle)
(Last)
CHILD’S
51. ADOPTEE’S NAME
(First)
(Middle)
(Last)
ADOPTED
NAME
52. CURRENT
(R.F.D., or St. or Box No.)
(City/Town)
(State)
(Zip Code)
MAILING
ADDRESS
IX. ADOPTIVE
53. PERSONAL SIGNATURE OF ONE OR BOTH OF THE ADOPTIVE PARENTS
PARENTS’
MOTHER/PARENT A
FATHER/PARENT B
SIGNATURE
X.
PROBATE
54. On the
day of
, 20
, the
Court of
COURT OR
County, in the State of
,
presiding, passed a decree of
FAMILY
(Name of Justice or Judge)
DIVISION
adoption in the case of the child and parents described above, recorded by microfilm
or in Vol.
, Page
, Record No.
Signed and sealed by:
Date:
20
(Judge, Register, Clerk)
NOTE:
When adoption takes place in New Hampshire and the child was born in New Hampshire, the court will forward copies of the
adoption report as shown. If the adoptee was not born in New Hampshire, the court will forward copies of the adoption report to
the Division of Vital Records Administration, who will forward the report to the respective state of birth.
a. Report sent to town clerk of
, 20
SEAL
b. Report sent to Div. of Children & Youth Services
, 20
Date:
c. Report sent to New Hampshire Division of Vital Records Admin.
, 20
XI. CITY/TOWN
To be completed by New Hampshire Town/City Clerk of Place of Birth
CLERK
55. Date received
56. Date forwarded to Div. of Vital Records Admin.
57. Signed
Clerk of
PAGE 2
Top of 1st Page
V.S.-37
03/08

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