Form Dh-527 - Certified Statement Of Final Decree Of Adoption

Download a blank fillable Form Dh-527 - Certified Statement Of Final Decree Of Adoption in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dh-527 - Certified Statement Of Final Decree Of Adoption with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

State of Florida

Department of Health - Office of Vital Statistics

CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION

(Important – Read Information and Instructions on reverse side before completion.)

A. INFORMATION REGARDING ORIGINAL STATUS OF CHILD

Birth Certificate No. __________________

(If Known)

1a. Child’s Name___________________________________________________________________

1b. Child’s Sex _________________

First

Middle

Last

1c. Child’s Date of Birth _______________________ 1d. Child’s Place of Birth _________________________________________________

City

State

Country

2a. Name of Father/Parent ____________________________________________________________ 2b. Father’s/Parent’s Race ____________

First

Middle

Last Name Prior to First Marriage (if applicable)

Suffix

3a.Name of Mother/Parent ____________________________________________________________ 3b. Mother’s/Parent’s Race ___________

First

Middle

Last Name Prior to First Marriage (if applicable)

Suffix

B. INFORMATION FOR A NEW CERTIFICATE OF BIRTH

1. Child’s Name After Adoption _________________________________________________________________________________________

(As shown in Final Judgment of Adoption)

First

Middle

Last

Suffix

FATHER/PARENT

MOTHER/PARENT

2a. Name: _________________________________________________

3a. Name: _______________________________________________

First

Middle

Last

Suffix

First

Middle

Last

Suffix

2b. Name prior to first marriage (if applicable) ____________________________

3b. Name prior to first marriage (if applicable) __________________

2c. Birth Date: __________________________________________

3c. Birth Date

: ___________________________________________

2d. Birth Place: __________________________________________

3d. Birth Place: __________________________________________

2e. Race: _______________________________________________

3e. Race: _______________________________________________

2f. Social Security Number: ________________________________

3f. Social Security Number: ________________________________

4. Residence Address of Adoptive Parent(s) at Time of Adoption:

_________________________________________________________________________________________________________________

Street, Apt. No. or Rural Route Number

City, Town, or Location

County

State

Inside City Limit

Zip Code

5. Mailing address if different from residence address:

__________________________________________________________________________________________________________________

⃞ Yes

⃞ No

6. Is this a single parent adoption?

⃞ Yes

⃞ No

7. Is this a stepparent or other relative adoption?

If yes, please state relationship _____________________

8. Person completing Part A and B of this Form:

8b. Relationship/Title _____________________________________

8a. Name: ______________________________________________

(If agency, list agency name & License #)

Type or Print

8c. Signature ____________________________________________________________ 8d. Telephone ______________________________

Signature of Person Completing Form

Area Code and Number

9a. Attorney/Pro Se Petitioner__________________________________9b.Bar No.__________ 9c.Telephone ____________________________

Type or Print

Area Code and Number

9d. Address __________________________________________________________________________________________________________

Street

City

State

Zip Code

“For infant adoptions: If you are interested in obtaining information on Florida’s Health Start Program and potential services available for your

infant, please call the Healthy Baby Hotline at 1-800-45- BABY (1-800-451-2229) and identify yourself as an adoptive parent.”

C. CERTIFICATE OF CLERK OF CIRCUIT COURT

._________________________

Court Docket No

1. On the _______ day of ______________________, 20_____, the Circuit Court of _________________________ County, _______________

Judge _______________________________ presiding, ordered a decree of adoption in the case of the child and the parents described above.

2a. Signed and Sealed by _________________________________________

2b. Date ____________________________________________

Clerk of Circuit Court

State Law requires a $20.00 fee made payable to “The Office of Vital Statistics” for filing a new birth certificate for a Florida birth resulting

FEE:

from adoption. This fee includes the issuance of one certification of the new certificate. Certification of the new certificate cannot be provided prior

to the payment of this fee.

Clear Form

DH 527, 04/2016, Florida Administrative Code Rule 64V-1.0031 (Obsoletes Previous Editions)