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\bRelevant article from our knowledge database
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