Form Adph-Hs 95 - Request For Pre-Adoption Or Other Birth Certificate From An Alabama Sealed File Page 2
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3REQUEST FOR PRE-ADOPTION OR OTHER BIRTH CERTIFICATE
FROM AN ALABAMA SEALED FILE
WHO MAY REQUEST A COPY:
! ! ! ! The person named on the birth certificate -- no other family member.
! ! ! ! Person must be 19 years of age or older.
! ! ! ! Person must have been born in Alabama.
! Person must have had an original birth certificate removed from the files due to an adoption, legitimation or paternity
determination.
WHAT THE APPLICANT WILL RECEIVE:
! ! ! ! The applicant will receive a copy of the original birth certificate clearly marked that it is not a certified copy and it may not
be used for legal purposes. Note that the information on the birth certificate in the file is shown as it was provided by the
birth parent (s) at the time of birth. The information may or may not be accurate.
! The applicant will receive copies of all other documents in the “sealed file” which often include the legal documents from
the court where the adoption or paternity determination took place or other legal documents for a legitimation. These files
do not contain medical or other information about the birth parents.
! ! ! ! In the case of persons who were adopted, the revision of the law in 2000 allows birth parents to submit a Contact
Preference Form which will be placed in the sealed file upon receipt. If a Contact Preference Form is in the file at the time
the original birth record is requested, it will be sent to the applicant.
HOW TO ORDER:
! ! ! ! The fee to search for and provide one non-certified copy of a birth certificate from a sealed file is $25.00. This fee
includes copies of the legal documents in the sealed file with the original birth certificate. Fees are non-refundable.
Make check or money order payable to “Alabama Vital Records.”
! ! ! ! Provide as much of the following information as possible for us to locate your current birth certificate, which is necessary
to locate the sealed file. You must complete & sign the Applicant Section or your request cannot be processed. For
additional information or questions call 334.206.5426.
MAIL THIS FORM TO:
CENTER FOR HEALTH STATISTICS
P.O. BOX 5625
MONTGOMERY, ALABAMA 36103-5625
BIRTH:
FULL NAME AS IT CURRENTLY
APPEARS ON BIRTH CERTIFICATE
FIRST
MIDDLE
LAST
DATE OF BIRTH
SEX
COUNTY OF BIRTH
HOSPITAL
FULL MAIDEN NAME OF MOTHER
AS IT CURRENTLY APPEARS
ON BIRTH CERTIFICATE
FIRST
MIDDLE
LAST
FULL NAME OF FATHER
AS IT CURRENTLY APPEARS
ON BIRTH CERTIFICATE
FIRST
MIDDLE
LAST
APPLICANT SECTION (THIS SECTION MUST BE COMPLETED)
Amount Enclosed $
Anyone falsely applying for a record is subject to a penalty upon conviction of up to three months in the county jail or a fine of up
to $500. Code of Ala. 1975, § 13A-10-109. By signing, you are certifying you have a legal right to the record requested.
YOUR SIGNATURE
DATE
PRINT YOUR NAME
DAY TIME PHONE (
)
ADDRESS
CITY
STATE
ZIP
ADPH-HS 95/REV. 10/2009
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