This form is to be used in drafting a report for adoption. Download
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STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH, DIVISION OF VITAL RECORDS 3 CAPITOL HILL, RM. 101, PROVIDENCE, RI 02908-5097 REPORT OF ADOPTION INSTRUCTIONS FOR PART I: Attorney must complete Parts I and II. Items 1-10 should be co mpleted with information about the parent(s) whose names should appear on the new certificate of birth. Information for BOTH parents must be listed unless this is a “single parent” adoption where the new birth certificate will show only one parent’s name. DO NOT USE LIQUID CORRECTION FLUID ON THIS FORM . INFORMATION FOR NEW BIRTH CERTIFICATE: Parent’s First Name Middle Name Birth Last Name Present Name 1A. 1B. 1C. 1D. Parent’s Date of Birth (Mo., Day, Yr.) Birt hplace (State or Foreign Country) Race 2. 3. 4. Parent’s Social Security Number Parent ’s City or Town AND State of Residence at Time of Child’s Birth 5. 6. Parent’s First Name Middle Name Birth Last Name Present Name 7A. 7B. 7C. _________ 7D. Parent’s Date of Birth (Mo., Day, Yr.) Birt hplace (State or Foreign Country) Race 8. 9. 10. Parent’s Social Security Number 11. Present Mailing Address of Adoptive Parents: Street Address, City, State, Zip Code 12. Name of: Attorney, Agency Handling Adoption or Pro Se Telephone Number 13A. ______________________________________________________________________ 13B. Address of: Attorney, Agency Handling Adoption, or Pro Se 14. 15. IF YOU DO NOT WANT A NEW BIRTH CERTIFICATE CREATED, CHECK THIS BOX INSTRUCTIONS FOR PART II: Items 16-21 below should list information as it appears on this child’s CURRENT birth certificate. It will be used to locate and seal the current certificate of birth after this adoption is finalized. ___________________________________________ _________________ Child’s First Name Middle Name Last Name 16A 16B 16C Child’s Sex Date of Birth (Mo., Day, Yr.) Birthplace (City/town, county, and state) 17. 18. 19. Parent’s First Name Middle Name Birth Last Name Present Name 20A. 20B. 20C. 20D. Parent’s First Name Middle Name Birth Last Name Present Name 21A. 21B. 21C. 21D. 22 . CERTIFICATION I hereby certify that the child descri bed in items 16-21 above was adopted by the parent(s) listed in Items 1-12 above OF CLERK OF on this date (mo/day/yr): and, as set forth in the decree of adoption made COURT on that date in Family Court Case Number , the child shall now bear the name of: (FIRST NAME) (MIDDLE NAME) (LAST NAME) 23. 24. (SIGNATURE OF RI FAMILY COURT CLERK) (DATE OF SIGNATURE) 25. Court Clerk in and for the County of _________________________________________________________________________________________ _, Rhode Island VS 86 (Rev. 11/13) FURTHER INSTRUCTIONS ON THE REVERSE SIDE OF THIS FORM INSTRUCTIONS for Item 22: The Clerk of the Court should complete this item, affix the seal of the court, and forward form to: Division of Vital Records 3 Capitol Hill, Rm. 101 Providence, RI 02908-5097 NOTE: If this adopted child was born in another state or US territory, the RI state registrar shall forward this report to the state registrar or other appropriate of ficial at the place of birth. FEES Required by Law : There is a fee of $15.00 for processing the adoption and creating the new birt h certificate. Make check payable to “General Treasurer, State of Rhode Island” and send to the Division of Vital Records. Certified copies of the new bi rth record will be issued to the parent(s) or the attorney after the processing fee is paid and a request for a certified copy is made. The fee for one certified copy of a birt h record is $20.00. Additional certified copies of the same birth record issued at the same time are $15.00 each. Applicatio ns and information for obtaining certified co pies of vital events can be found on our web site. www.health.ri.govRelevant article from our knowledge database
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