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Application For a Non-Certified Record of Birth Prior To Adoption

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MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH	 	REGISTRY OF VITAL RECORDS AND STATISTICS  150 MT. VERNON STREET, 1st Floor  
DORCHESTER, MA 02125 -3105   
 
APPLICATION FOR A NON- CERTIFIED RECORD OF BIRTH PRIOR TO ADOPTION   
(Please print legibly.) 	 	RVRS USE ONLY	 	Rec’d_____________ 
#_________________ 
Cert #___________ __ 
Completed_________ 
Initials__________ ___	
 	
 
Please fill out and return this form to the address above.  If you are requesting a record by mail, make your check or money order payable to the 
Commonwealth of Massachusetts  and include  $32.00 for each  copy requested.  DO NOT SEND CASH THROUGH THE MAIL. Records requested  
in -person  at the Registry counter are $20.00 per copy.  Checks, money orders, and cash are accepted at the counter.  Credit/debit cards are not 
accepted.  See additional instructions on the reverse of this form.  
 
SUBJECT OF THE RECORD (ADOPTEE)	 	 	Number 	 	of Copies:  	
Full Name on Current Birth Record (n	ame at adoption) 	(First, Middle, Last)	 	Date of Birth	* (Month, Day, Year)	 	 	 	 	 	
Full 	Name of A	doptive Mother	/Parent	 (First, Middle, Last)	 	Maiden surname of Adoptive Mother	 	 	 	 	 	
Full 	Name of Adoptive Father	/Parent	 (First, Middle, Last)	 	City/Town of Birth	 	 	 	 	 	
Name on Pre	-Adoption Birth Record (name at birth), if known 	 	 	 	 	
 
PERSON MAKING REQUEST  
Full Legal Name (Current Name) 	(First, Middle, Last)	 	Relationship to Adoptee	 	 	 	 	Self	 	Adoptive parent	 	Adult child of deceased adoptee Legal guardian of child (under 18 years) of a deceased adoptee	 	Mailing Address	 	Telephone number	(s) 	(Street/PO Box/Ap	t. #)	 	 	 	
(City/Town, State, Zip)	 	 	
AF F I DAV I T	 OF  AP P L I CANT	 (If you are applying by mail, you must 	sign	 and date this section in the presence of a notary.)	 	WARNING:   Providing false information under this oath or affirmation is punishable by fine and imprisonment under M.G.L. c.268 §6.  
 
I hereby swear or  affirm under the penalties of perjury that the information on this application  is true to the best of my knowledge and belief.  
 
          ________________________________________________________  _______________________ 
                Signature        Date 
 
On this _______________ day of ___________________________, ____________ before me, the undersigned notary public, personally  appeared 
____________________________________________________________________ who proved to me through satisfactory evidence of identification, 
which  were __________________________________________________________, to be the person whose name is signed  on this document and 
who swore or affirmed to me that the contents of the document were truthful and accurate to the best of their knowledge and belief and that they signed 
this form voluntarily for its stated purpose.      Notary Public _____________________________________________________ 
              My Commission Expires: ____________________________________________  
 
IDENTIFICATION AND SUPPLEMENTAL DOCUMENTATION (see additional information on the reverse of this form) 
IDENTIFICATION 	If you are applying in	-person you will need to show 	one	 of the following identification documents.  If you are applying by	 mail, you 	must enclose a clear, legible, photocopy of the identification document.   Alternative identification documents require prior approval by RVRS.  Valid, non	-expired, driver’s license	  	 Valid, non	-expired, identification card 	issued by a department of motor vehicles  	
Valid, non	-expired, passport	  	
DOCUMENTATION 	If you are applying in	-person and additional documentation is required	 (see reverse of form)	, you 	must	 provide an original certified 	copy for inspection.  If you are applying by mail and additional documentation is required, you must send an original certified copy that will be returned to you 	with	 completion of your order.	 	Proof of 	name change	:  	Certified copy of a marriage certificate 
 Certified copy of a legal change of name decree 
Other (specify):	 	
Proof of death:	  	Certified copy of death certificate 
 	Proof of relationship:	 	 Certified copy of your birth certificate  Certified copy of legal guardianship 	
*Records on file at the Registry of Vital Records and Statistics date back to 1926.  Earlier records are housed at the State Archives.  	Form R	-109 (04/2016	)

APPLICATION FOR RECORD OF BIRTH PRIOR TO ADOPTION 
Application Instructions 
 
Who May Apply? Beginning December 5 , 2007, certain individuals  specified by state law may apply for  a copy of an initial birth record established prior to an  adoption 
(without first obtaining a judicial court order) : 	
 	Adoptees who were born in Massachusetts on or before July 14, 1974.  	
 	An adult child (18 years or older) of a deceased parent who was an adoptee born in Massachusetts on or before July 14, 1974.  	
 	The parent or guardian of a child (under 18 years of age) whose deceased parent was an adoptee born in Massachusetts on or before July 14, 
1974. 
 
Beginning January 1, 2008, the following additional individuals  specified by state law  may also apply:  	
 	The adoptive parent of a child (under 18 years of age) born in Massachusetts on or after January 1, 2008.  
 
Beginning January 1, 2026, the following additional individuals specified by state law may also apply:  	
 	An adult adoptee (18 years or older) who was born in Massachusetts on or after January 1, 2008. 
 	
Submit  your application by mail  or in person  
If you are applying by mail, you must include copies of all identification and documentation listed below, and your signature must be notarized.  The fee 
for applying by mail is $32.00.  Please do not send cash by mail.   Checks and money orders should be made payable to the “Commonwealth of 
Massachusetts.”  Credit and debit cards are not accepted. RVRS will also  accept applications by walk-in customers.  If you are applying in person, y our 
application will be reviewed for completeness, your identification and documentation will be checked, payment will be taken, and the application will be 
processed in the order it was received.  The fee for applying  in person  is $20.00.   
 
What you will  receive  if, after processing of your application, RVRS locates your birth record prior to adoption  
You will receive a  copy of the birth record that was registered with RVRS prior to adoption  that lists among other items, the legal parent or parents listed 
on the record at the time of birth.  In a very few cases, there may have been an amendment prior to the adoption, for which you will receive the initial 
record and any relevant amendments (e.g., paternity establishment).  
 
The copy will be made on security paper to deter potential fraudulent use, and will contain, the following statement mandated by state law:  “The 
contents of this birth record are being released under section 2B of chapter 46 of the Massachusetts General Laws or under a court order.   This record 
was amended by adoption.   This is not a certified copy of a birth record.”   
 
Refunds  If the application can not be processed for any reason, it will be returned to you with a refund.   
 
If you do not sign for the record that is sent to you by certified mail, and the record is returned to RVRS, you will NOT be issued a refund, as the cost 
has already been incurred.  
 
Identification Requirements   
1.  If you are applying for your OWN record:  
 
A current government -issued photo ID . (F or applications by mail, attach a photocopy of the ID):  	
 	Current, not expired, driver’s license, or 	
 	Current, not expired, other ID issued by your state’s department of motor vehicles, or  	
 	Current, not expired, passport 	
 	If you cannot provide one of the identification items listed above, please call RVRS to be certain the ID you plan to  provide is adequate. 
 
Do cumentation of a change of name.   If the name on your ID is different from your name at the time of your adoption, you must provide documentation 
that will prove you are the person listed on the birth record. (F or applications by mail, attach an original certified copy of the requested documentation.  
Your original documents will be returned to you with the completed order).  For example:  	
 	If your ID shows a married name, provide a certified copy of your marriage certificate that shows your name as it appears on your current 
(adoptive)  birth certificate and your name  after marriage as it appears on your ID. 	
 	If your ID reflects a legal change of name, provide a certified copy of your legal change of name decree that shows your name as it appears on 
your current (adoptive) birth certificate and your legal  name  as decreed by a court and as appears on your ID. 
 
2.   If you are  applying for YOUR PARENT’S record:  
 
You must provide the identification listed above in numbered section 1, AND also show or provide:  	
 	A certified copy of your parent’s death record.  If you are applying by mail, attach an original certified copy of your parent’s death record.  	
 	A certified copy of your birth record that shows you are the decedent’s child. If you are applying by mail, attach an original certified copy of 
your parent’s death record. 	
 	Documentation of any change of name  not reflected on the death certificate.  If your parent’s death certificate does not contain in some format 
a reference to his or her name at the time of adoption (e.g, maiden name, or name at birth or adoption), then you will need to provide evidence 
of the change of name as described above  in numbered section 1. 
 
3.   If you are applying for YOUR ADOPTED CHILD’S record (beginning January 1, 2008):  	
 	You must provide the identification listed above in numbered section 1. 
 	
For all requests submitted by  mail , notarization is required: For requests by mail only, sign  and date your application in the presence of a notary who will certify that your signature is authentic.  
 
Questions  Contact the Registry of Vital Records and Statistics at (617) 740- 2600 or by email at vital.recordsrequest@state.ma.us	. 	 	Form R	-109 (11/2007)
Next: Adopted Person or Person Acting on His or Her Behalf Previous: Affidavit Disclosing Care or Custody Proceedings
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