Udoh-Ovrs-300 - Application For Birth Certificate
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For Vital Records Only
IMPORTANT
READ REVERSE SIDE PRIOR TO FILLING OUT THIS FORM
VALID ID IS REQUIRED of the person signing the application. See reverse side
for more information.
TYPE OF ADOPTION/COURT ORDER
Two New Parent
Single Parent
Legitimation
Adoption
Adoption
Paternity
NII Health History
NII Health History
Certified Marriage License AND
Certified Report of Adoption
Certified Report of Adoption
Voluntary Declaration of
Paternity signed by both parents
Step Parent
Foreign Adoption
Court Ordered
Certified Foreign Report of Adoption –or-
Adoption
Certified Report of Adoption WITH Certified
Paternity
Certified Report of Adoption
Order Establishing Facts of Birth
Certified Court Order of Paternity
Family Adoption
NII Health History
Certified Report of Adoption
CHILD’S IDENTIFYING INFORMATION
___________________________________________________________
Child’s ORIGINAL Birth Name
(Name on Current Birth Certificate)
First
Middle
Last
_________________________________________________
Child’s NEW Adoptive/Court Ordered Name
First
Middle
Last
_________________________
_____________________________
Child’s Birth Date
Child’s Birth Place
(City, County, State or Country)
________________________________________________________________
Name of BIRTH Mother
First
Middle
MAIDEN LAST
PARENT’S INFORMATION
(to be listed on the NEW birth certificate)
This information is REQUIRED for ALL adoptions/court orders, including Step-Parent Adoptions and
Court Order Paternities.
_____________________________________________________
Mother/Parent’s FULL MAIDEN Name
First
Middle
MAIDEN LAST
___________________________________________________
Mother/Parent’s Address at Time of Birth
______________________
___________________
Mother/Parent’s Birth Date
Mother/Parent’s Birth Place
______________________________________________________
Father/Parent’s FULL MAIDEN Name
First
Middle
MAIDEN LAST
_______________________
___________________
Father/Parent’s Birth Date
Father/Parent’s Birth Place
_________________________________________________________
Adoption/Placing Agency, if known
:
RELATIONSHIP
Attorney
Agency
Parent
Self
Grandparent
I am
(please check one)
___________________________________________
_______________________
Your Signature
Date
___________________________________
______________________
Printed Name
Telephone Number
______________________________________________________________________
Mailing Address
City, State and Zip Code
NUMBER OF CERTIFIED COPIES REQUESTD
__1__First Copy ($60.00)
_____Additional Copies ($10.00 each)
Total Fee $____________________
Clerk’s Initials ________
PAID:
Check
Cash
Money Order
Credit Card
Request #___________________
UDOH-OVRS-300
REV. 01/2016
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