
A L A B A M A
REPORT OF ADOPTI ON
INSTRUCTIONS: Parts I and II of this report must be completed by the petitioners, their attorney, or the Court. If the child was placed by a licensed
child-placing agency or the State Department of Human Resources, information about 1) the natural parents, 2) place of birth of the child, and 3)
birth certificate number may be omitted. This information is to be furnished to the State Registrar by the agency which placed the child.
Within ten (10) days after the final decree of adoption has been made, the Clerk of the Court shall make his certification in Part III, affix his
official seal, and forward this report with the final decree of adoption to the State Registrar, Center for Health Statistics, P. O. Box 5625,
Montgomery, Alabama 36103-5625. If the child was born in Alabama a new certificate listing the child’s new name and adoptive parents will be
prepared. The fee to prepare this new birth certificate is $25.00 payable to the Alabama State Board of Health. This fee also includes one certified
copy of the new certificate. If the adopted child was not born in Alabama, the State Registrar will forward the certified copy of the final decree of
adoption and the report of adoption to the proper official in the state of birth. The fee to forward the final decree of adoption and report of adoption
to the proper official in the state of birth is $10.00 payable to the Alabama State Board of Health. To obtain a certified copy of this birth certificate,
contact the state of birth.
PART I INFORMATION ABOUT CHILD (To Identify Original Birth Certificate)
NOTE: If the official birth certificate number is entered, the names of the father and mother may be omitted.
Full Name of Child at Birth First Middle Last
Birth Certificate Number
Place of Birth City–Town or Location
State and Country of Birth
Date of Birth
Sex
Full Maiden Name of NATURAL Mother First Middle Last
Full Name of LEGAL Father First Middle Last
PART II INFORMATION AFTER ADOPTION (For New Birth Certificate)
Full Name of Child After Adoption First Middle Last
FATHER — Full Name First Middle Last
Father’s State of Birth (If not in U.S.A., name country)
Father’s Date of Birth
Father (Check One)
Adoptive Natural
MOTHER — Full Maiden Name First Middle
Last
Mother’s Legal Name First Middle Last
Mother’s Date of Birth
Mother’s State of Birth (If not in U.S.A., name country)
Mother’s Usual Residence—State
Mother’s Residence — County
Mother’s Residence — City or Town and Zip Code
Mother’s Residence — Street Address (If rural, give location)
Mother’s Residence — Inside City
Limits (Specify Yes or No)
Mother (Check One)
Adoptive
Natural
Mailing Address of Adoptive Parents
Phone Number
Name and Full Address of Attorney Or Agency Representative
Phone Number
Title
PART III CERTIFICATION OF CLERK OF COURT
Must be properly signed, dated and sealed.
Name of Court
For City, County
of
I hereby certify that the adoption as set forth above was made final in this Court by decree
dated
and bearing No.
.
Signature
(Seal) Title
By