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Report of Adoption

This form is to be used in drafting a report for adoption. Download

Extracted Text for Proper Search

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.gov
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