Free Adoption Application - New Hampshire

Clear Form

STATE OF NEW HAMPSHIRE
Department of State Division of Vital Records Administration
CONFIDENTIAL Report of City and Town Clerk Relative to an Adoption
TYPE OR PRINT ONLY

I.

CHILD

1. CHILD'S (First) NAME

(Middle)

(Last)

2.

DATE OF BIRTH

(Month) (Day) (Year)

3. SEX

CHILD 4. LOCATION (City/Town) (County) OF INFORMATION BIRTH AS IT APPEARS BEFORE 5. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND ADOPTION

(State/Country)

6. ANCESTRY? (English, French, Puerto Rican, etc.) Specify

AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 8. MEMBER SIBLING GROUP ADOPTED 9. PREVIOUS ADOPTIVE PLACEMENT? 7. SIBLINGS IN SUBSTITUTE TOGETHER? CARE? YES NO YES NO YES NO 10. SPECIAL Yes If Yes, Primary Basis: Age Racial/Ethnic Member Sibling Group Medical/Other Disability NEEDS No Other, Specify CHILD If Medical/Other, Check All That Apply Blind/Visually Impaired Deaf/Hard of Hearing Physically Disabled Mental Retardation Emotionally Disturbed Learning Disability Medical Condition Other, Specify: 11. DATE OF ADOPTIVE PLACEMENT (Month) (Day) (Year) 12. AUSPICES OF ADOPTION PUBLIC AGENCY TRIBAL AGENCY OTHER, SPECIFY INDEPENDENT PERSON PRIVATE AGENCY

13. LOCATION OF AGENCY/PERSON (State/Country)

II.

SUPPORT 14. ADOPTION SUBSIDY YES NO COMPLETE IF 15. SOURCES OF FINANCIAL SUPPORT (CHECK ALL THAT APPLY) STATE/FEDERAL TITLE IV-MONTHLY TITLE IV-E NON-RECURRING STATE ONLY TITLE XVI (SSI) SUPPORT FOR TITLES XIX/XX WITH NO PAYMENT NONE OF ABOVE, PARENTS ONLY CHILD OTHER, SPECIFY BIOLOGICAL 16. FATHER'S NAME (First) (If stated on FATHER
(Middle) (Last) 17. DATE (Month) (Day) (Year) OF BIRTH 19. ANCESTRY? (English, French, Puerto Rican, etc.) Specify

III.

birth certificate) 18. WAS TERMINATION OF PARENTAL RIGHT (Month) (Day) (Year) VOLUNTARY ­ Date of Surrender/Consent NON-VOLUNTARY ­ Date of Termination of Rights NOT APPLICABLE 20. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKAN NATIVE UNKNOWN OTHER, SPECIFY 21. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION

IV.

BIOLOGICAL 22. MOTHER'S MAIDEN SURNAME MOTHER
25. WAS TERMINATION OF PARENTAL RIGHT VOLUNTARY ­ Date of Surrender/Consent NON-VOLUNTARY ­ Date of Termination of Rights NOT APPLICABLE 27. RACE WHITE BLACK CHINESE/JAPANESE AMERICAN INDIAN/ALASKAN NATIVE 28. MARITAL STATUS MARRIED SEPARATED DIVORCED SINGLE

23. DATE OF BIRTH (Month)

(Month) (Day) (Year)

24. MOTHER MARRIED AT BIRTH OF CHILD? YES NO

(Day)

(Year)

26. ANCESTRY? (English, French, Puerto Rican, etc.) Specify

OTHER ASIAN/PACIFIC ISLANDER UNKNOWN OTHER, SPECIFY

CIVIL UNION WIDOWER

CIVIL UNION DISSOLUTION

(Continued on Back)
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V. ADOPTIVE 29. MOTHER's/ (First) PARENT A's MOTHER/ NAME PARENT A
32. RACE

(Middle)

(Last)

30. MAIDEN NAME
(If applicable)

31. DATE (Month) (Day) (Year) OF BIRTH 33. ANCESTRY? (English, French, Puerto Rican, etc.) Specify

WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 34. STATE OF BIRTH 35. RESIDENCE (Street Address) AT TIME OF CHILD'S BIRTH: 36. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION

(City/Town)

(County)

(State)

37. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE 39. MAIDEN NAME
(If applicable)

BIOLOGICAL MOTHER CO-PARENT 40. DATE (Month) (Day) (Year) OF BIRTH

VI. ADOPTIVE 38. FATHER's/ (First) FATHER/ PARENT A's NAME PARENT B
41. RACE

(Middle)

(Last)

WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 43. STATE OF BIRTH 44. RESIDENCE (Street Address) AT TIME OF CHILD'S BIRTH: 45. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION

42. ANCESTRY? (English, French, Puerto Rican, etc.) Specify

(City/Town)

(County)

(State)

46. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE

BIOLOGICAL FATHER CO-PARENT

VII.

INCOME

47. FAMILY INCOME OF ADOPTIVE PARENTS

Under $25,000 $35,000 ­ $44,999

$25,000 ­ $34,999 $45,000 ­ $54,999

$55,000 and over

VIII. ADOPTIVE 48. PARENTS

WE DO NOT WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION. 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: (First) (First) (First) (Middle) (Middle) (Middle) (Last) (Last) (Last)

49. MOTHER'S/PARENT A's NAME 50. FATHER'S/PARENT B's NAME

CHILD'S 51. ADOPTEE'S NAME ADOPTED NAME
52. CURRENT MAILING ADDRESS

(R.F.D., or St. or Box No.)

(City/Town)

(State)

(Zip Code)

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 OR , County, in the State 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. Date: (Judge, Register, Clerk) NOTE: 20 Signed and sealed by:

Court of presiding, passed a decree of

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 SEAL b. Report sent to Div. of Children & Youth Services c. Report sent to New Hampshire Division of Vital Records Admin. 56. Date forwarded to Div. of Vital Records Admin. Clerk of , 20 , 20 , 20

Date:

XI. CITY/TOWN CLERK

To be completed by New Hampshire Town/City Clerk of Place of Birth 55. Date received 57. Signed

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