Free adoptreportNEWe.pmd - Colorado

STATE OF COLORADO

REPORT OF ADOPTION
This form can be filled out and printed at the following Web address: www.cdphe.state.co.us/certs/adoptreport.pdf This document must contain the signature and seal of the District/Juvenile court and cannot be submitted online.
first 1. CHILD'S ADOPTIVE NAME: PARENTS: THE INFORMATION IN ITEMS 1-3 WILL APPEAR ON THE CHILD'S NEW BIRTH CERTIFICATE first middle middle last

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2. MOTHER'S NAME

last (prior to first marriage)

PLEASE CHECK PARENT'S ROLE IF OTHER THAN MOTHER:

COPARENT state

FATHER country if not U.S.A.

2A. PARENT'S BIRTH DATE 3.FATHER'S FULL NAME: first

2B. PARENT'S BIRTH PLACE: middle last

PLEASE CHECK PARENT'S ROLE IF OTHER THAN FATHER:

COPARENT state

MOTHER country if not U.S.A

3A. PARENT'S BIRTH DATE 4. PARENTS' CURRENT LEGAL NAMES: 4A. PARENTS' CURRENT MAILING ADDRESS: city/town state

3B. PARENT'S BIRTH PLACE:

street or box # zip 4B. DAYTIME PHONE #: -- --

5. TYPE OF ADOPTION (Check only one; see item C. on page 2):

TWO PARENT ADOPTION

STEP PARENT ADOPTION

SINGLE PARENT ADOPTION Attorney ID#:

SECOND PARENT ADOPTION

ATTORNEY OR AGENCY (To be contacted for additional information if needed) 6.CONTACT NAME: street or box # 6B. ADDRESS: 6C. CONTACT PHONE #: -- --

6A. FIRM OR AGENCY: city/town state zip

6D. E-MAIL ADDRESS:

7. A NEW BIRTH CERTIFICATE WILL BE PREPARED UNLESS BOX IS CHECKED no 7A. WAS THE CHILD BORN IN A FOREIGN COUNTRY? yes no (If yes see item D. on page 2) (see items E, F, and G on page 2) last state last last

THIS INFORMATION IS NEEDED TO LOCATE AND SEAL THE CURRENT BIRTH CERTIFICATE first middle 8. CHILD'S CURRENT NAME ON CERTIFICATE: county 8B. BIRTHDATE: first 9. MOTHER'S NAME PRIOR TO FIRST MARRIAGE first 10. FATHER'S NAME: CERTIFICATION OF CLERK OF COURT middle 8C. BIRTHPLACE: middle

-----------8A. GENDER: country if not U.S.A

I hereby certify that the child identified above was adopted by the above named parents on the ________ day of ___________________, 20_____ and is now to bear the name of _____________________________________________________________________________________________ as set forth in the decree of Adoption in the District/Juvenile Court of ________________________________County, Colorado.

Case number _______________ Signature and seal of court _______________________________________________ Date _____/_____/_______

By _____________________________________________________ Deputy Clerk
Return form to: Vital Records/Adoption Specialist Colorado Department of Public Health and Environment 4300 Cherry Creek Drive South HSVR-VR-A1 Denver, CO 80246-1530 Contact information: Vital Records Adoption Specialist Phone: 303-692-2227 E-mail: [email protected]

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adoptreport.pmd rev. 07/08

INSTRUCTIONS FOR COMPLETING THIS FORM *Do Not Include Payment With this Form

A. An electronic version of this form can be filled out and printed by going to the following Web address: www.cdphe.state.co.us/certs/adoptreport.pdf. You must then submit this form to the District/Juvenile court for their signature and seal. The court will mail the completed report to Vital Records per C.R.S. 25-2-107 (1). B. Colorado law (C.R.S. 25-2-107 and 25-2-113) authorizes the preparation of a new birth certificate for an adopted person born in Colorado. Please complete this form carefully to avoid unnecessary delay in filing the new birth certificate. * Upon completion of the new birth certificate, a notification along with an application for a certified copy of a birth certificate will be sent to the attorney listed in Item #6. If an attorney is not listed the notification will be mailed to the adoptive parent(s) at the address provided in Item #4A. C. "Two parent" means two new parents will be listed on the new birth certificate. "Step parent" means one new parent and one original parent will be listed on the new birth certificate. "Single parent" means one new parent will be listed on the new birth certificate. Information about the other parent will be left blank. "Second parent" means the child has a sole legal parent, and the sole legal parent wishes the child to be adopted by a specified second adult. D. Residents of Colorado who are adopting a child born in a foreign country must submit the Report of Adoption and a certified copy of the Final Decree of Adoption, or Finding of Birth Facts or Validation of Foreign Adoption form. E. Birth certificates for children born in a foreign country to a citizen of the United States must be obtained through the U.S. Department of State. If either one of the birth parents was a U.S. citizen at the time of the child's birth, the adoptive parents should contact the U.S. Department of State for a revised birth certificate for their child at: Correspondence Branch Passport Services 1111 19th St. NW, Ste 510 Washington, DC 20522 F. The current birth certificate will be pulled from the working files and indices and placed in a sealed file along with the report of adoption. This sealed file shall not be subject to inspection except as provided in section 25-2-113.5, upon order of a court of competent jurisdiction, or as provided by regulation. G. For children born outside of Colorado, the Department of Public Health and Environment Vital Records Office will forward the report of adoption to the state vital statistics office in the state where their child was born. E-mail: [email protected]
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