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Illinois Certificate of Adoption

In the case of wanting to adopt a child in the State of Illinois, the following form has to be completed and submitted.

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CER T\bF \bC ATE  \f F A D\f PT\b\f N	
Ch\bl D ’s  \bN F\f Rm AT\b\f N A T B \bR Th	
                                                                                                                    Date  o f                                              Sta te  file
N am e __________________________________________________     bir th _______________________     num ber __________________
Pla ce  o f b ir th
H osp it a l,  c it y  s ta te  a nd c o u ntr y ______________________________________________________________________________________
M oth er/C o-P are nt’s  n am e p rio r to  fir s t m arria ge/c iv il  u nio n                      Fath e r/C o-P are nt’s  n am e p rio r to  fir s t m arria ge/c iv il   u nio n
______________________________________________________     _______________________________________________________
o	M ale      	o	Fem ale                 If fo re ig n b o rn , h a s Illin ois  p re vio usly  c re ate d a  b ir th  r e co rd  fo r th is  c h ild ?     	o	Yes      	o	N o
Has a ny U .S . s ta te  p re vio usly  c re a te d a  b ir th  r e co rd  fo r th is  c h ild ?      	
o	Yes      	o	N o      If y e s, w ha t s ta te ? __________________________	
Ch\bl D ’s  N Am E A FTE R  A D\f PT\b\f N	
Fir s t                                                                     Mid dle                                                               Last
n am e(s ) _____________________________     nam e(s ) ___________________________     nam e(s ) __________________________	
PA REN T’s  \bN F\f Rm AT\b\f N A FTE R  A D\f PT\b\f N	
o	 C o-p are nt       	o	 N atu ra l           	o	 A do ptiv e          	o	 S in g le              	o	 C o-p are nt       	o	 N atu ra l           	o	 A doptiv e          	o	 S in gle	    	                          	 f a th er                   fa th er                    fa th er                 	                              moth er                  moth er                  moth er
M arrie d?	
o	Y es	o	N o In  a  C iv il  U nio n?	o	Y es	o	N o Marrie d?	o	Y es	o	N o In  a  C iv il  U nio n?	o	Y es	o	N o
Full  n am e p rio r to  fir s t m arria ge/c iv il  u nio n                                                  Full  n am e p rio r to  fir s t m arria ge/c iv il  u n io n
______________________________________________________        ______________________________________________________
D ate  o f b ir th ____________________________________________         Date  o f b ir th ____________________________________________
Pla ce  o f b ir th ___________________________________________         Pla ce  o f b ir th ___________________________________________
Socia l  S ecu rit y  n um ber ___________________________________         Socia l  S ecu rit y  n um be r ___________________________________
C urre nt le gal  n am e_______________________________________         Curre nt le ga l  n am e ______________________________________
Sig natu re  o f                                                                                                  Sig n atu re  o f
th is  p are nt______________________________________________         th is  p are nt _____________________________________________	
B y s ig nin g th is  fo rm , y o u a re  v e rif y in g th at a ll  in fo rm atio n lis te d is  tr u e                     By s ig nin g th is  fo rm , y o u a re  v e rif y in g th at a ll  in fo rm atio n lis te d is  tr u e 
and c o rre ct.                                                                                                                  and c o rre ct.	
A DDREssEs	
Adoptiv e  p are nt( s )’  a d dre ss a t th e tim e o f th is  c h ild ’s  b ir th .  S tr e et___________________________________________________________
C it y ____________________________________     Sta te ________     ZIP  C ode ______________     County __________________________
A tto rn ey’s  c u rre nt m ailin g a ddre ss a nd te le phone n um ber _________________________________________________________________
A doptiv e  p are nt( s )’  c u rre nt m ailin g
addre ss a nd te le phone n um ber______________________________________________________________________________________
D o y o u w ant a  n ew  b ir th  c e rtif ic a te  c re ate d?  	
o	Y es   	o	N o                  If y e s, s e n d th e n ew  b ir th  c e rtif ic a te  to   	o	A tto rn ey    	o	P are nts	
C ER T\bF \bC AT\b\f N	
Sta te  o f Illin ois , C ounty  o f _______________________________     Case  N um ber __________________     Decre e D ate _______________
I h ere by c e rtif y  th at a  d ecre e o f a doptio n w as e nte re d b y th e C ir c u it  C ourt o f th is  c o unty  o n th e a bove  lis te d d ate  w hic h  a dju dged th at th e a bove  m entio ned
ch ild  is  d ee m ed to  b e fo r le ga l  in te nts  a nd p urp ose s th e c h ild  o f th e a doptiv e  p are nts  id entif ie d a bove .
D ate ___________________________________
C O URT S EAL
S ig ne d _________________________________	
State of Illinois
Illinois Department of Public Health  	Div is io n o f V it a l  R eco rd s	
9 2\f E . R id gely  A ve .
S prin gfie ld , IL  6 27\b2-2 737

\bl l\bN \f \bs  D EPA R Tm EN T \f F P U Bl\bC  h EA lT h  
Div is io n O f  V it a l  R eco rd s	
92\f E . R id gely  A ve .
S prin gfie ld , IL  6 27\b2-2 737	
C ER T\bF \bC ATE  \f F A D\f PT\b\f N	
The c e rtif ic a te  o f a doptio n m ust b e c o m ple te d in  it s  e ntir e ty . F ailin g to  c o m ple te  a ny p ortio n o f th is  fo rm  c o uld  r e su lt  in  th e
docu m ent b ein g r e tu rn ed to  y o u w it h out th e a doptio n in fo rm atio n b ein g p la ce d o n th e b ir th  r e co rd . T he fe e fo r c o m ple tin g th e
bir th  r e co rd  o f a n Illin ois  b orn  c h ild  is  $ 1\f. T his  in clu des o ne c e rtif ie d c o py o f th e n ew  b ir th  c e rtif ic a te . A ddit io nal  c o pie s o rd ere d
a t th e s a m e tim e a re  $ 2 e ach . M ake  c h eck o r m oney o rd er p aya ble  to  Illin ois  D epartm ent o f P ublic  H ealt h  o r ID PH .
If y o u a re  s u bm it tin g a  c e rtif ic a te  o f a doptio n r e gard in g a  fo re ig n b orn  c h ild , y o u m ust s u bm it  o ne a ddit io nal  d ocu m ent a s
pro of o f th e c h ild ’s  p la ce  a nd d ate  o f b ir th . R eco rd s o f fo re ig n b ir th  a re  $ \f e ach .
If th e a dopte d c h ild  w as b orn  in  a  s ta te  o th er th an Illin ois , th is  c e rtif ic a te  o f a doptio n w ill  b e fo rw ard ed to  th e s ta te  o f b ir th .
P le ase  ty p e o r p rin t a ll  in fo rm atio n c le arly . If y o u h ave  a ddit io nal  q uestio ns, c a ll  th e D iv is io n o f V it a l  R eco rd s a t 
2 17-7 82-6 \f\f3. O ff ic e  h ours  a re  1 \b a .m . to  3  p .m ., M onday th ro ugh F rid ay.
C hild ’s  in fo rm atio n a t b ir th
In dic a te  th e c h ild ’s  fu ll  n am e a t b ir th ; m onth , d ay a nd y e ar o f b ir th ; h osp it a l,  c it y , s ta te  a nd c o untr y  ( if  o th er th an th e U nit e d
S ta te s) o f b ir th . If th e s ta te  file  n um ber o f th e b ir th  r e co rd  is  k n ow n, in dic a te  s o . P ro vid e th e fu ll  n am es o f th e b io lo gic a l
m oth er/c o -p are nt a nd fa th er/c o -p are nt. In dic a te  th e s e x o f th e c h ild . If y o u a re  s u bm it tin g a n a doptio n r e gard in g a  fo re ig n b orn
c h ild , h as th e s ta te  is su ed a  b ir th  r e co rd  fo r th is  c h ild  in  c o nnectio n w it h  a  p rio r a doptio n in  Illin ois ?  If y o u a re  s u bm it tin g a n
adoptio n r e gard in g a  fo re ig n b orn  c h ild , h as a ny s ta te  in  th e U nit e d S ta te s p re vio usly  e sta blis h ed a  b ir th  r e co rd  fo r th is  c h ild ?
If s o , in  w hat s ta te .
C hild ’s  n am e a fte r a d optio n
In dic a te  in  th e a ppro pria te  s p ace  th e c h ild ’s  fir s t, m id dle  a nd la st n am e(s ). D o n ot u se  w hit e  o ut o r lin e th ro ugh a ny p art o f th e
new  n am e. If a lt e ra tio ns a re  m ade, a  c e rtif ie d c o py o f th e a doptio n d ecre e w ill  b e r e quir e d.
P are n t’s  in fo rm atio n a fte r a d optio n
In dic a te  if  e ach  p are nt is  a  c o -p are nt, n atu ra l  fa th er, n atu ra l  m oth er, a doptiv e  fa th er o r a doptiv e  m oth er, o r if  th is  is  a  s in gle
p are nt a doptio n. In dic a te  if  e ach  p are nt is  m arrie d o r in  a  c iv il  u nio n. G iv e  e ach  p are nt’s  fir s t, m id dle  a nd la st n am e p rio r to  fir s t
m arria ge o r c iv il  u nio n. P ro vid e e ach  m onth , d ay a nd ye ar o f b ir th ; a nd th e s ta te  o r c o untr y  ( if  o th er th an th e U nit e d S ta te s) o f
bir th  fo r e ach . E ach  p are nt’s  S ocia l  S ecu rit y  n um ber is  r e quir e d; if  e it h er p are nt d oes n ot h ave  a  S ocia l  S ecu rit y  n um ber,
p le ase  s o  in dic a te . E ach  p are nt m ust s ig n v e rif y in g h is /h er r e sp ectiv e  in fo rm atio n.
A ddre sses
T he a ddre ss o f th e a doptiv e  p are nt( s ) a t th e tim e o f th e c h ild ’s  b ir th  is  r e quir e d. P ro vid e th e c o m ple te  a ddre ss in clu din g a ny
apartm ent n um ber, c it y , s ta te , Z IP  c o de a nd c o unty . If th e b io lo gic a l  m oth er/c o -p are nt is  a ls o  a  p are nt a fte r a doptio n, th en h er
ad dre ss fr o m  th e o rig in al  b ir th  r e co rd  w ill  b e p la ce d  o n th e n ew  b ir th  r e co rd . T he a tto rn ey’s  c o m ple te  a ddre ss a nd te le phone
nu m ber a re  r e q uir e d. T he c u rre nt a ddre ss a nd  te le pho ne n u m ber o f th e a do ptiv e  p a re nt( s ) a re  a ls o  r e quir e d. In dic a te  if  a  n ew
bir th  r e co rd  is  to  b e  c re ate d a nd  to  w hom  it  is  to  b e s e nt.
C ertif ic atio n
T his  m ust b e c o m ple te d b y th e  c ir c u it  c le rk ’s  o ff ic e  in  th e c o unty  w he re  th e  a d op tio n  w as c o m ple te d. T he  c ir c u it  c le rk  m ust
in clu de h is /h er s e al.	
P rin te d b y A uth orit y  o f th e S ta te  o f Illin ois IO CI 1 2-1 \b6	V R  1 6\b
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