Adoption Report

This form is to be used when drafting an Adoption Report. This is required for all adoptions.Download

Extracted Text for Proper Search

ADOPTION REPORT	
45-24 (01/16)	
THIS IS A PERMANENT RECORD — PLEASE TYPE OR PRINT ONLY	
The $35 fee for amendment of Oregon birth certificate may be submitted with this form. 
The $35 fee does not include a certified copy of the new certificate.  
One short-form certificate is $25. 
One full-image, long-form certificate is $30 (available for 1903-2007). 
Mail to: Center for Health Statistics, P.O. Box 14050, Portland, Oregon 97293- 0050	
PART I	PLEASE FURNISH INFORMATION AS TAKEN FROM ORIGINAL BIRTH RECORD.
THIS INFORMATION IS NECESSARY TO LOCATE THE ORIGINAL BIRTH CERTIFICATE.	
FACTS OF  BIRTH	
1. Name of child — First  Middle name  Last name 1A. Sex
2. Date of birth 3. Name of physician, if known
4A. Place of birth — Hospital 4B. City4C. State (if not in U.S.A., name country)	
NATURAL 
PARENTS’  D ATA	
5. Name of mother — First  Middle name Maiden name Last name
6. Name of father — First  Middle name Last name
7. U.S. citizenship — Was natural mother a U.S. citizen when child was born?
   No   Ye s	8. U.S. citizenship — Was natural father a U.S. citizen when child was born?  No   Ye s	
PRIOR 
ADOPTION	9. Was the child listed above previously adopted in the united states?   No   Ye s
  If yes, please complete item #10.	10. State/County of adoption:	
PART II	PLEASE ENTER INFORMATION BELOW AS IT IS TO APPEAR ON THE NEW BIRTH RECORD.	
If any information is left blank, it will be blank on the birth certificate.
All information requested below MUST be provided or a new birth certificate cannot be completed for filing.
MOTHER
(check one)	
 	Adoptive	
 	Natural 	
 	Parent A	
11. Current legal name of mother/parent A — First  Middle name Last name
11A. Legal/Maiden name at birth of mother/parent A — First  Middle name  Last name at mother’s birth/maiden name
12. Date of birth 13. State of birth (if not in U.S.A., name country) 14. Social Security Number
15. Mother’s residence at time of child’s birth 15A. Residence street address
15B. State (if not in U.S.A., name country) 15C. County 15D. City15E. Zip code15F. Inside city limits?	
  No   Ye s	
FATHER
(check one)
 	Adoptive	
 	Natural 	
 	Parent B	
16. Name of father/parent B — First  Middle name Last name
17. Date of birth 18. State of birth (if not in U.S.A., name country) 19. Social Security Number
20A. If adoptive person is an adult, is new birth  record to be issued?
  No   Ye s	20B. Is this a step-parent adoption?  No   Ye s	20C. Is this a single-parent adoption?  No   Ye s	
AGENCY	21. Agency or person through which child was obtained	
ATTORNEY	22A. Name (print or type) 22B. Mailing address  Zip code22C. Telephone	
ADOPTIVE 
PARENTS	23A. Current mailing address 23B. Telephone	
PART III	The clerk of the court should require that as much of the information as is available in parts I and II  
be completed before certification is made and the report mailed to the registrar of vital statistics.	
24. I hereby certify that an adoption decree was filed on the
     Day of   20 
  Case no. 	
25. Adopted name of child as set forth in decree
  First name  Middle name Last name	
26. Signature of
 Clerk of court    County of  	
Center for Health Statistics	
COURT SEAL: