[PPT] - Adoptions CDCAT Winter Conference Leslie Olmos Adoption Timeline PowerPoint Presentation

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Adoptions

CDCAT Winter Conference

Leslie Olmos

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Adoption Timeline

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Start to Finish

Family and Child Match Obtain Court Order Adoption File New Birth Record Done!

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Certificate of Adoption

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Completing COA

Either submit the CERTIFIED COA ONLY or UNCERTIFIED COA w/order
If filing as:
Single parent, order and COA must have parent’s name
1 Step-Adoptive/1 Biological, order and COA must have both
Same-Sex Couple, both parents on order and COA(can choose titles on COA)
If order contradicts un-certified COA, will be rejected.
Please designate 1 party to submit ALL documents and fees
If no fees are attached, adoption will be filed BUT record will not be

issued until fees are provided

Court order must have at LEAST: Initials/name of child, DOB, gender
“Parents’ rights terminated”, no longer needed in order

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CAR(Central Adoption Registry)

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Should I register for CAR?

Voluntary System for adult adoptee, birth parent, or sibling to place name on registry and

locate other registered family members without going through the courts or spending high fees.

Requirements
Open to all below who are 18 years or older
Adult Adoptee(born and/or placed for adoption in Texas)
Birth Parents
Biological siblings of adult adoptee
May also apply with adoption agency that handled case, if registry is available.
ALL parties must register for there to be a match.
Information released with submissions of:
Consent to Release of Identifying Information
1 hour Post-Adoption Counseling Session
Written biography/history about the participant’s life with copies of photos. Sent to other

participant once information is exchanged.

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HSEGH

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HSEGH Report

Health, Social, Education and Genetic History Report
For all non-relative private adoptions, no adopting agency involved
Attorneys must submit report and addendum to VSS prior to

consummation

Report is certified by VSS and receipt is sent to attorney; report may be

waived by court

HSEGH (completed by attorney)
Addendum (completed by birth parents)
Cover Sheet(completed by attorney)
No fees required

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Sealed Records

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Request to Open Sealed Records

The contents of a sealed file will be released if a customer submits a certified copy of a court
rder signed by the judge of the court that granted the adoption. If the applicant is unsure where

the adoption was granted, they will want to start with requesting an Identity of court.

The court order must include the following:
Child’s full name after adoption
Child’s full date of birth
Child’s place of birth
The order must instruct DSHS-Vital Statistics to open the sealed file
The customer must provide the following:
Current and Valid ID (court ordered name change or marriage license if the name on the ID does not match

what is on the “current” birth record.

$10.00 fee
The birth of the registrant must be in Texas. If the registrant was adopted in Texas, but was born in

another state we will reject the open sealed file request and refer the customer to the state they were born in.

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Tips

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Avoid Rejections

DO NOT USE WHITE OUT, nor scratch/cross-out information
Have ALL signatures
Please use Mother/Parent’s maiden names
Include ALL fees requested for type of adoption
Use ONE payment for request, not multiple checks/money orders, attach to

adoption papers (no loose documents)

Submit CURRENT forms of identification
Use LEGAL names of petitioners
ALL parties must register for CAR for future information attainment
Attorneys/Families/Clerks: Check if a child’s name has previously been

amended

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HB 123

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New Legislation: HB 123

House Bill 123 states: On the request of a child or youth, the State Registrar, Local Registrar, or

County Clerk shall issue without Fee or Parental Consent a certified copy of the child’s birth record to a homeless child or youth, a child in managing conservatorship of DFPS, or a young adult over 18 but under 21 who resides in foster care placement.

“Certification of Homeless Status for Texas Birth Certificate” form aids local registrars issuing

these birth certificates without fees.

“Foster Care Verification” form is issued by DFPS case workers and used to obtain birth certificate

fee waiver.

How do I waive?
On top of application for record request, write HB 123
Submit application to State, document that record was issued under HB 123
Credit on next month’s invoice

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Forms/Resources

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Forms and Links

https://www.dshs.state.tx.us/vs/reqproc/faq/mardiv.shtm#adopt (Adoption FAQ)
https://www.dfps.state.tx.us/Child_Protection/Adoption/default.asp (DFPS Adoption)
Forms (Birth, Death, Adoption, Paternity, Abortion)
VS 143 – Request for Identity of Court of Adoption
VS 2271 – Central Adoption Registry Application and Instructions
VS-210 Central Adoption Registry Request for Open Records
VS 145 – Adult Adoptee Application for Non-Certified Copy of Original Birth Certificate

(info)

VS 160 – Certificate of Adoption (for attorneys and district clerks)
VS 166.531 – Validation Petition
VS 166.532 – Validation Order
CAR
Health, Social, Education and Genetic History Reporting Forms
Voluntary Central Adoption Registry Registration Application
Goodson V. Castellanos (Interesting adoption legal case)

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Q & A

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Thank you!

Adoptions (CDCAT Winter Conference)

Leslie.olmos1@dshs.Texas.gov

SLIDE 21 Original birth certifjcates: If you are an adult adoptee who can identify the names of the parents listed on your original birth certifjcate, you may be eligible to receive a plain-paper copy of it. An application to request the original birth certifjcate is located on the Vital Statistics (VS) web page: http://www.dshs.state. tx.us/vs, (under adoption) or contact us at 1/888/963- 7111 if you would like one mailed. Adoption records are confjdential. The court, child- placing agency and VS have various records relating to the adoptee. Court: The clerk who represents the adopting court

ften has copies of all documents submitted during the

adoption process. An individual may petition this court to unseal these records. If the petitioner presents good cause to the presiding judge, the judge may order the record open. Child-Placing Agencies: A licensed child-placing agency maintains a fjle on each child it places for

adoption. The adult adoptee and the adoptive parents

are eligible to receive de-identifjed copies or summa- rized descriptions about the birth family. If the adoptee does not know the name of the agency, then he/she may wish to contact the Central Adoption Registry (see below). Vital Statistics (VS): If an adoptee was born in Texas, VS typically has the original birth certifjcate and a certifjcate of adoption that amends the original birth information with the adoptive information. If the adult adoptee cannot identify the birth parents on the original birth certifjcate (see New Legislation above) then the adoptee may wish to apply to the Central Adoption

Registry. At the same time, the adoptee may wish to

request the identity of the original adopting court to petition for the release or unsealing of the record. International Adoptions: Texas residents who have adopted a child internationally in that child’s home country can request a Texas-issued foreign-born birth certifjcate by registering the foreign adoption in the county where the adoptive parents reside. Vital Statistics (VS) provides medical and social information to adoptees and other eligible persons via two types of records: the Health, Social, Education and Genetic History report (HSEGH) and out-of-business child-placing agency records.

In 1984, Texas started collecting medical and social

information on birth families if the child was being privately placed without the aid of an agency. Adult adoptees, adoptive parents and other qualifjed persons may obtain non-identifjed information from these reports.

If one was placed for adoption by a child-placing

agency, the agency is responsible for issuing non- identifying information from the HSEGH and other records concerning the birth family.

Years after the adoption, the birth family may wish

to provide current social, medical and genetic history relevant to the health and well-being of the

adoptee. Once received, VS will attempt to locate

the adoptive parents and inform them of the infor-

mation. If the adoption occurred through an existing

child-placing agency, the birth family must contact that agency.

The Central Adoption Registry (CAR) Unit main-

tains many, but not all, adoption records from child- placing agencies that have ceased operation. Adult adoptees and their adoptive parents may obtain social and medical history from those records. The purpose of the Central Adoption Registry is to reunite adult adoptees with birth parents or siblings who register looking for them. The registry is unique in that it has the authority, without a court order, to view a sealed fjle or confjdential record. Since VS houses the

riginal birth certifjcate, guesswork is rarely involved

in determining the biological relationship. Identify- ing information is released when all parties involved complete the following:

1. Attend a one-hour post-adoption counseling

session to help educate and prepare one for a reunion.

2. Prepare an autobiography with photographs.

The registry exchanges the biographies at the same time it releases identifying information.

Adoption Information Medical/Social Information Central Adoption Registry (CAR)

New Legislation New Legislation

Adoption Information Medical/Social Information Central Adoption Registry (CAR)

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Central Adoption

Registry Requirements

A person must be adopted in Texas, or be born in Texas

and adopted in another state; or

Be the birth parent or sibling of the adoptee; and
Be 18 years of age or older.
Provide proof of age and identity (copy of birth cer-

tifjcate and a valid government-issued photo ID).

$30 check or money order, payable to DSHS.

To receive an application, call or write the Central Adoption Registry (CAR) at: VSU-CAR (MC 2096) POB 149347 Austin, TX 78714-9347 512/776-7388 or Toll Free: 1/888/963-7111 x7388 Or, Visit the Texas Department of State Health Services Vital Statistics web site to print an application: http://www.DSHS.state.tx.us/vs Publication No. 35-11068 07/2009

Texas Adoption Information

& The Central Adoption Registry

Texas Department of State Health Services Vital Statistics Texas Department of State Health Services Vital Statistics VSU-CAR (MC 2096) P.O. Box 149347 Austin, Texas 78714-9347

Central Adoption

Registry Requirements

Texas Adoption Information

& The Central Adoption Registry

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FOSTER CA

RE V ERIFICA TION Form K-908-4200 Revised September 2019 Purpose: Use this form to prov ide a y

uth or y
ung adult with an official statem

ent that the y

uth or y
ung adult

was in foster care through the Tex as D epartm ent of Fam ily and Protectiv e S erv ices (D FPS ) at any tim e after the y

uth
r y
ung adult’s 13th birthday

. This form prov ides proof that the y

uth or y
ung adult is currently in or was prev

iously in foster care, which m ay be needed to access certain program s or benefits. Directions: The casework er or another D FPS staff m em ber v erifies the D FPS record of the y

uth or y
ung adult,

com pletes this form , and giv es it to the y

uth or y
ung adult.

For questions contact the Pr e p aratio n fo r A d u lt Liv in g ( PA L) p r

gram

. FOSTER CA RE V ERIFICA TION STA TEMENT Use an X to m ark the appropriate box: This form v erifies that this y

uth or y
ung adult is currently or was prev

iously in foster care through the D epartm ent of Fam ily and Protectiv e S erv ices (D FPS ) as follows: The y

uth is currently under age 18 and is in the m

anaging conserv atorship of D FPS . The y

ung adult is at least age 1

8 but under age 21 and resides in a foster care paid placem ent. The y

uth or y
ung adult was in foster care at any tim

e after the y

uth or y
ung adult’s 13th birthday and left

foster care because of adoption, fam ily reunification, or em ancipation. The y

ung adult left foster care at age 18 or older.

INFORMA TION A BOUT YOUTH OR YOUNG A DULT Nam e: D ate of B irth: Youth or Young Adult D FPS Person Identification Num ber (PID ): INFORMA TION A BOUT DFPS STA FF MEMBER COMPLETING THIS FORM Nam e: Title: Phone (with area code): Em ail A ddress: @ dfps.state.tx .us S ignature:

X

D ate S igned: Page 1 of 1

SLIDE 24 MAIL COMPLETED DOCUMENTS TO: VS-CAR (MC 1966) POB 149347 Austin TX 78714-9347 Questions: 512/776-7388 VITAL STATISTICS HEALTH, SOCIAL, EDUCATION & GENETIC HISTORY REPORT (Please add information not listed on the original report) ORIGINAL BIRTH INFORMATION NAME OF CHILD (AT BIRTH) FIRST MIDDLE LAST DATE OF BIRTH (mm/dd/yyyy) SEX NAME OF HOSPITAL (OR SPECIFY IF HOME BIRTH) CITY COUNTY OR REGION STATE OR PROVINCE COUNTRY NEW NAME OF CHILD AFTER ADOPTION FIRST MIDDLE LAST SUFFIX I BIOLOGICAL MOTHER BIRTH MOTHER FIRST MIDDLE LAST (MAIDEN) LAST (MARRIED) BIRTHPLACE (STATE OR FOREIGN COUNTRY) RACE SSN (IF KNOWN) DATE OF BIRTH (mm/dd/yyyy) LAST PLACE OF RESIDENCE CITY COUNTY STATE ZIP COUNTRY BIOLOGICAL FATHER BIRTH FATHER FIRST MIDDLE LAST DATE OF BIRTH (mm/dd/yyyy) BIRTHPLACE (STATE OR FOREIGN COUNTRY) RACE SSN (IF KNOWN) LAST PLACE OF RESIDENCE CITY COUNTY STATE ZIP COUNTRY ADOPTIVE PARENT ADOPTIVE PARENT FIRST MIDDLE LAST (MAIDEN) DATE OF BIRTH (mm/dd/yyyy) BIRTHPLACE (STATE OR FOREIGN COUNTRY) RELATIONSHIP: STEP-PARENT OTHER RELATIVE NON-RELATIVE BIOLOGICAL MOTHER RACE SSN (IF KNOWN) ADDRESS CITY COUNTY STATE ZIP COUNTRY ADOPTIVE PARENT ADOPTIVE PARENT FIRST MIDDLE LAST DATE OF BIRTH (mm/dd/yyyy) BIRTHPLACE (STATE OR FOREIGN COUNTRY) RELATIONSHIP: STEP-PARENT OTHER RELATIVE NON-RELATIVE BIOLOGICAL FATHER RACE SSN (IF KNOWN) ADDRESS CITY COUNTY STATE ZIP COUNTRY CHILD PLACING AGENCY NAME ADDRESS CITY COUNTY STATE ZIP COUNTRY COURT IDENTITY OF ADOPTION STATE COUNTY COURT CAUSE # APPROXIMATE CONSUMMATION DATE WARNING: THIS IS A GOVERNMENTAL DOCUMENT. TEXAS PENAL CODE, SECTION 37.10, SPECIFIES PENALTIES FOR MAKING FALSE ENTRIES OR PROVIDING FALSE INFORMATION IN THIS DOCUMENT. Rev 11/2015

SLIDE 25 CAUSE NO.________________ IN THE INTEREST * IN THE DISTRICT COURT * OF * COUNTY, TEXAS * A CHILD * JUDICIAL DISTRICT HEALTH, SOCIAL, EDUCATIONAL, AND GENETIC HISTORY REPORT I. HEALTH HISTORY Birth name of child: New name of child: Place of birth: Date of birth: Type of delivery: Prenatal and labor complications, if any: Prenatal distress, if any: Birth weight: lbs.

zs.

Birth length: ins. Apgar scores: 1 minute: 5 minutes: Abnormal findings, if any, in physical examination at birth: Initial rate of growth and development: (Within normal or abnormal limits as to each? Explain any abnormal notations.) Height: Weight: Head circumference: Attainment of developmental milestones: (Normal or abnormal? Explain if abnormal.) Record of immunizations: Type Date Remarks

SLIDE 26 Childhood diseases: Type Date Remarks Traumas, accidents, or illnesses requiring medical treatment or hospitalization: Type Date Remarks Results of available medical examinations: Type Date Remarks Psychological History and results of available psychological examinations, including the dates of evaluation, any diagnosis, and a summary of findings: Psychiatric history and results of available psychiatric examinations, including the dates

f evaluation, any diagnosis, and a summary of findings:

Dental history and results of available dental examinations: Has the child ever been the victim of physical, sexual, or emotional abuse? If so, please detail that abuse: II. SOCIAL HISTORY Information regarding past and existing relationships among child and-- Siblings (names, ages, and present residences): Extended family members (names, addresses and relation): Other persons who have had physical possession of or legal access to child (names and addresses): III. EDUCATIONAL HISTORY Educational institutions in which child has been enrolled: Summary of child's performance at such institutions:

SLIDE 27 Name and results of any educational/standardized tests administered to child: Summary of special educational needs: IV. GENETIC HISTORY Information Concerning Biological Mother Name: Birth date: Birthplace: Attainment of developmental milestones, include the age at which she crawled, walked, talked, cut teeth, etc.: (Normal or abnormal? Explain if abnormal.) Nationality and ethnic background: Height: Weight: Eye color: Hair color: Religious background, if any: Health status at time of placement. *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological mother, including, but not limited to, drug and/or alcohol abuse (stating whether such condition occurred during pregnancy), diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when

available. Specifically include all genetic diseases and disorders.)

Highest level of formal education completed: Professional status/achievements: Any psychological, psychiatric, or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation

SLIDE 28

f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received: Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance: Information Concerning Biological Father Name: Birth date: Birthplace: Attainment of developmental milestones, include the age at which he crawled, walked, talked, cut teeth, etc.: (Normal or abnormal? Explain if abnormal.) Nationality and ethnic background: Height: Weight: Eye Color: Hair color: Religious background, if any: Health status at time of placement: *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological father including, but not limited to, drug and/or alcohol abuse, diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when available. Specifically include all genetic diseases and disorders.) Highest level of' formal education completed: Professional status/achievements: Any psychological, psychiatric, or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation
f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received:

SLIDE 29 Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance: Information Concerning Maternal Grandmother Name: Birth date: Birthplace: Nationality and ethnic background: Height: Weight: Eye Color: Hair color: Religious background, if any: Health status at time of placement: *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological maternal grandmother, including, but not limited to, drug and/or alcohol abuse, diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when available. Specifically include all genetic diseases and disorders.) Highest level of formal education completed: Professional status/achievements: Any psychological, psychiatric; or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation
f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received: Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance:

SLIDE 30 Information Concerning Maternal Grandfather Name: Birth date: Birthplace: Nationality and ethnic background: Height: Weight: Eye Color: Hair color: Religious background, if any: Health status at time of placement: *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological maternal grandfather including, but not limited to, drug and/or alcohol abuse, diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when available. Specifically include all genetic diseases and disorders.) Highest level of formal education completed: Professional status/achievements: Any psychological, psychiatric; or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation
f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received: Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance: Information Concerning Paternal Grandmother Name: Birth date: Birthplace:

SLIDE 31 Nationality and ethnic background: Height: Weight: Eye Color: Hair color: Religious background, if any: Health status at time of placement: *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological paternal grandmother including, but not limited to, drug and/or alcohol abuse, diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when available. Specifically include all genetic diseases and disorders.) Highest level of formal education completed: Professional status/achievements: Any psychological, psychiatric; or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation
f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received: Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance: Information Concerning Paternal Grandfather Name: Birth date: Birthplace: Nationality and ethnic background: Height: Weight: Eye Color: Hair color: Religious background, if any:

SLIDE 32 Health status at time of placement: *If applicable, cause of and age at death: Health and medical history: (list every serious medical condition, illness, or disease experienced by biological paternal grandfather including, but not limited to, drug and/or alcohol abuse, diabetes, cardiac condition, cancer, giving details, such as period of condition, treatment, and prognosis, when available. Specifically include all genetic diseases and disorders.) Highest level of formal education completed: Professional status/achievements: Any psychological, psychiatric; or social evaluations, including the dates of the evaluations, any diagnosis, and a summary of findings: Any criminal conviction record relating to a misdemeanor or felony classified as an

ffense against the person or family or classified as public indecency or a felony violation
f a statute intended to control the possession or distribution of a controlled substance,

including the date, type of conviction, and penalty received: Any information that would indicate that the child is entitled to or eligible for state or federal financial, medical, or other assistance: By signature below, the adoptive parents acknowledge receipt of a copy of this report. Date : Signature, Adoptive Parent Signature, Adoptive Parent

SLIDE 33 CENTRAL ADOPTION REGISTRY REQUEST FOR OPEN RECORDS In 1984, we started collecting and maintaining social and medical information on private non-related adoptions. We also have records from many out-of-business child-placing agencies. To review the list of available records that we maintain, please visit us online at: http://www.dshs.state.tx.us/vs/reqproc/adoptagencies.shtm As required by law, we will redact the confidential portion of the record. Specifically, Texas Family Code §162.018 - Access to Information, requires us to edit the record to protect the identity of the biological parents and any other person whose identity is confidential. TO REQUEST A COPY OF YOUR RECORD, PLEASE COMPLETE THE FOLLOWING: The more information you are able to provide us with will help us locate and process your request promptly. Today’s Date I am the:

□ Adoptee □ Adoptive Parent □ Other ______________________________

Full Adopted Name (Including Maiden) The Adopted Person is a:

□ Male □ Female

Adoptee’s Date of Birth Adoptee’s Place of Birth Child Placing Agency:

□ Unknown

State and County of Adoption:

□ Unknown

Adoptee’s Age at adoption:

□ Newborn □ Toddler □ Child □ Teenager

Adoptive Father’s Name: Adoptive Mother’s Name (including her maiden name): Your Name Today: Your Mailing Address: City State Zip Phone: ( ) Email Address: Reason(s) for requesting records: □ Medical □ Heritage □ Proof of adoption □ Other (please explain)

□ Informed of updated medical by the adoption registry.

__________________________________________________ ______________________ Signature Date Your request must be accompanied with a copy of a valid photo ID, i.e., a copy of your driver’s license, passport, or State identification, and copy of a government-issued document that includes your maiden name, if applicable We will respond to your request within 10 business days after the date it is received by our department. Once you have completed this form, please send it along with a copy of the requested identification to: Central Adoption Registry (MC 1966) PO Box 149347 Austin, Texas 78714-9347 PLEASE NOTE: If your record is 50 pages or less, there will not be a charge assessed to receive a copy. If the record is 50 pages or more, we will contact you with an estimate before proceeding with processing the record. VS-210 Rev. 6/2015

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S A M P L E

SLIDE 35 VSRE _____________________________________ STATE OF TEXAS CERTIFICATE OF ADOPTION THIS IS A PERMANENT RECORD – PLEASE TYPE OR PRINT ONLY SECTION 1 PLEASE FURNISH THE BIRTH CERTIFICATE INFORMATION CURRENTLY ON FILE IN THE VITAL STATISTICS OFFICE. THIS INFORMATION IS NECESSARY TO LOCATE THE BIRTH CERTIFICATE

1. NAME OF CHILD (BEFORE THIS ADOPTION)

FIRST MIDDLE LAST

2. DATE OF BIRTH (mm/dd/yyyy)
3. SEX
4. TIME OF BIRTH
5. NAME OF HOSPITAL
6. CITY
7. COUNTY
8. STATE OR FOREIGN COUNTRY
9. PARENT

FIRST MIDDLE LAST MAIDEN

10. PARENT

FIRST MIDDLE LAST MAIDEN ORIGINAL BIRTH INFORMATION SECTION 2 PLEASE ENTER THE INFORMATION AS IT IS TO APPEAR ON THE NEW BIRTH RECORD. All information below MUST be provided or a new birth certificate cannot be completed. Single-Parent Adoption – Complete Only The Appropriate Information Regarding The Adopting Parent

12. Is This a Single Parent Adoption?
11. Is This a Step-Parent Adoption?
13. Do You Want The Birth Record Changed Based on the Adoption Decree?

Yes No Yes No Yes No PARENT

14. TITLE OF PARENT

MOTHER FATHER PARENT Adoptive

15. NAME OF PARENT

FIRST MIDDLE CURRENT LAST NAME LAST NAME BEFORE MARRIAGE Bi

16. DATE OF BIRTH
17. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
18. PARENT’S SOCIAL SECURITY NO. (WILL NOT APPEAR ON THE BIRTH
logical

CERTIFICATE) PARENT

19. TITLE OF PARENT

MOTHER FATHER PARENT Adoptive

20. NAME OF PARENT

FIRST MIDDLE CURRENT LAST NAME LAST NAME BEFORE MARRIAGE Biological

21. DATE OF BIRTH
22. PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)
23. PARENT”S SOCIAL SECURITY NO. (WILL NOT APPEAR ON THE BIRTH

CERTIFICATE) PARENT(S) ADDRESS AT THE TIME OF CHILD’S BIRTH

24. STREET ADDRESS

CITY COUNTY STATE ZIP

25. INSIDE CITY LIMITS?

Yes No PARENT(S) CURRENT ADDRESS

26. STREET ADDRESS

CITY STATE ZIP

27. PARENT(S) TELEPHONE NUMBER:
28. PARENT(S) EMAIL ADDRESS
29. SIGNATURE OF PARENT(S)

MAIL BIRTH CERTIFICATE TO: SECTION 3 30. MAILING ADDRESS CITY Attorney Parent(s) Clerk’s Office PLEASE PROVIDE THE INFORMATION BELOW FOR THE CENTRAL ADOPTION REGISTRY

31. BIOLOGICAL MOTHER

FIRST MIDDLE LAST (MAIDEN)

32. SSN
33. BIOLOGICAL MOTHER’S DATE OF BIRTH
34. BIOLOGICAL MOTHER’S PLACE OF BIRTH
35. BIOLOGICAL FATHER

FIRST MIDDLE LAST

36. SSN
37. BIOLOGICAL FATHER’S DATE OF BIRTH
38. BIOLOGICAL FATHER’S PLACE OF BIRTH
39. NAME OF ATTORNEY OF RECORD
40. ATTORNEY’S EMAIL ADDRESS
41. MAILING ADDRESS OF ATTORNEY
42. TELEPHONE NUMBER
43. NAME OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR
44. MAILING ADDRESS OF CHILD PLACING AGENCY OR MANAGING CONSERVATOR
45. TELEPHONE NUMBER

STATE ZIP

46. NAME OF THE CHILD AS SET FORTH IN THE ADOPTION DECREE:

FIRST MIDDLE LAST 47. CENTRAL ADOPTION REGISTRY INFORMATION ATTORNEY PLACING AGENCY OR MANAGING CONSERVATOR SECTION 4 CERTIFICATION OF THE COURT Please complete the child’s name as set forth in the Decree of Adoption I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AS STATED IN THE DECREE OF ADOPTION WHICH WAS GRANTED ON _______________DAY OF________________________,___________IN THE____________________COURT OF ________________ COUNTY, TEXAS IN CAUSE #__________________________. DISTRICT CLERK’S SIGNATURE Warning: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing a form which contains a false statement is 2 to 10 years imprisonment and a fine of up to $10,000. (Health & Safety Code, §195,003) VS-160 REV 8/2015

SLIDE 36 VSRE CERTIFICATE OF ADOPTION INSTRUCTIONS These instructions are designed to assist you in the proper completion of the Certificate of

Adoption. Should you have any questions,

please contact our office toll free at 888-963-7111 for assistance. PLEASE TYPE OR PRINT LEGIBLY. SECTION 1 The information in this section relates to the child’s information currently

n file in the Vital Statistics Office. Enter the name of the

child prior to adoption in item 1. This information must be supplied to enable us to locate the adoptee’s current certificate of birth. SECTION 2 Item #11 If this is a step-parent adoption, the information concerning the biological parent (s) MUST also be furnished. Item # 12 If this is a single parent adoption, please complete the appropriate information regarding adopting parent. A step-parent adoption is not a single-parent adoption. Item #13 If a NEW certificate is to be prepared, mark “YES”. Items #14 through #28 this information relates to the adoptive

parents. Some
f this

information will be transferred to the NEW certificate of birth. Item #30 should be completed to indicate if the Attorney, Parent(s), or District Clerk will receive the new birth certificate and provide the current mailing address of the recipient. SECTION 3 Items #31 through #38 are for the Central Adoption Registry. Please provide the requested information obtained on the biological parent(s) at the time of the adoption and/or termination of parental rights. Items #39 through #42 Enter the name, mailing address, email address and telephone number of the attorney of record. Items #43 through #45 Enter the information relating to the child placing agency or managing conservator. SECTION 4 Items #46 through #47, should be completed by the Clerk of the Court. This section MUST be completed to show the child’s name after adoption as shown in the final decree of adoption. If Section 4 is not completed by the clerk of the court granting the adoption, a CERTIFIED COPY of the final decree of adoption MUST be attached to the certificate of adoption form and will be retained by our

ffice.

EXPLANATION OF FEES: FOR CHILDREN BORN IN TEXAS OR A FOREIGN COUNTRY, THE FEE TO FILE A NEW BIRTH CERTIFICATE BASED ON ADOPTION IS $47.00. THE $47.00 FEE INCLUDES THE REQUIRED $25.00 FEE TO FILE THE ADOPTION AND THE $22.00 FEE TO ISSUE ONE CERTIFIED COPY OF THE NEW BIRTH CERTIFICATE. (ADDITIONAL CERTIFIED COPIES ARE $22.00 EACH) THE $15.00 CENTRAL ADOPTION REGISTRY (CAR) FEE IS REQUIRED ON EACH ADOPTION DECREE GRANTED IN TEXAS. IF THE CHILD WAS BORN IN ANOTHER STATE AND THE ADOPTION WAS GRANTED IN TEXAS, ONLY THE $15.00 CAR FEE IS REQUIRED. FOR ADOPTIONS GRANTED IN OTHER US STATES OR TERRITORIES THE CENTRAL ADOPTION REGISTRY FEE OF $15.00 IS NOT REQUIRED. A TOTAL FEE OF $62.00 MAY BE SUBMITTED IN ONE PAYMENT MADE PAYABLE TO TEXAS VITAL STATISTICS. MAIL THE PROPERLY COMPLETED CERTIFICATE OF ADOPTION WITH THE APPROPRIATE FEES TO: VITAL STATISTICS UNIT TEXAS DEPARTMENT OF STATE HEALTH SERVICES PO BOX 12040 AUSTIN TX 78711-2040 Warning: It is a felony to falsify information on this document. The penalty for knowingly making a false statement on this form or for signing a form which contains a false statement is 2 to 10 years imprisonment and a fine of up to $10,000. (Health & Safety Code, §195,003) VS-160 REV 8/2015

SLIDE 37 Parent 1: First Middle, Last name prior to first marriage (Maiden Name). Please separate with a space between first, middle and last name. Place of Birth Step 1: YOUR INFORMATION AND SHIPPING ADDRESS (PLEASE PRINT) Your Name (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name. Step 2 : INFORMATION FOR PERSON NAMED ON BIRTH CERTIFICATE (PLEASE PRINT) Full Name on Certificate (First, Middle, Last Name, Suffix) Please separate with a space between first, middle and last name. Street Address City State Zip Code E-mail Address Daytime Phone Number First, Middle, Last Name, Suffix Please separate with a space between first, middle and last name. Address to Send Certifjcate to if difgerent than noted above City State Zip Code Other: ____________________________ Reason for Request: Newborn Travel/Passport Records School Insurance Step 3 : COST & FEES (FEES NON-REFUNDABLE) Date of Birth Month Day Year City County State All orders are returned free of charge by USPS regular mail. For urgent requests, orders may be EXPEDITED by sending the order through an overnight mail service, such as: FEDEX, LoneStar, or UPS AND selecting one of the overnight return shipping methods below. Select Certifjcate Type: Long Form Birth Certifjcate Short Form Birth Certifjcate Texas Flag Heirloom Birth Certifjcate Bassinet Heirloom Birth Certifjcate Birth Verification Military Personnel with current deployment orders Qty Price/each Total x $22.00 $ $ $ $ $ Total Due $ $27.95 $5.00 $9.95 $13.00 x $22.00 x $60.00 x $60.00 x $22.00 Exempt Expedite Overnight Mail (for shipping within USA) $8 for Overnight Mail + $5 for Expedited processing Priority Mail (for shipping to Overseas Military Address ONLY) $4.95 for Overnight Mail + $5 for Expedited processing USPS Express Mail (for shipping overnight to PO Box ONLY) $22.95 for Overnight Mail + $5 for Expedited processing ONLY applications for birth certificates (NOT birth verifications) submitted by mail need to be notarized STATE OF ___________________________________ COUNTY OF _________________________________ This instrument was acknowledged before me on ___________________________ by _________________________________________________________________ (Date) (Name of person acknowledging) __________________________________ (Notary Public’s Signature) (Personalized Seal) Signature of Applicant VS - 140 (9/18) OFFICE USE ONLY CASH CHECK MONEY ORDER REMIT No. DATE CREDIT CARD (walk in only) AMOUNT$ FILED BY STAFF Your relationship to Person named

n Certificate: Self / Parent

Other-Specify _______________________ TEXAS BIRTH CERTIFICATE APPLICATION PLEASE PRINT. APPLICATION MUST BE ORIGINAL (INCLUDING SIGNATURE). NO CROSS OUT OR WHITE OUT WILL BE ACCEPTED. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST. I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home Visitation Program administered by the Offjce of Early Childhood Coordination of Health and Human Services. I authorize mailing to the address below, if mailing to address other than listed above.

Parent 2: First Middle, Last name prior to first marriage (Maiden Name). Please separate with a space between first, middle and last name.

TEXAS ONLY SEE INSTRUCTIONS ON BACK. BIRTH CERTIFICATE NUMBER 142 - DOCUMENT CONTROL NUMBER(S) WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT ON THIS FORM OR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003.) READ & SIGN (If record is not found, the fees are not refundable and are kept. If record is not on file, VSS will issue a "not found" letter.) Date Signed (MM/DD/YYYY) __ __ / __ __ / __ __ __ __ Step 4 : AFFIDAVIT

SLIDE 38 NO ________________________________ EX PARTE IN THE DISTRICT COURT ________________________ _________ JUDICIAL DISTRICT ET UX _______________ COUNTY, TX APPLICATION FOR ORDER RECOGNIZING VALIDITY OF FOREIGN DECREE OF ADOPTION, NOTARIAL ACT OF ADOPTION, *AND FOR CHANGE OF NAME TO THE HONORABLE JUDGE OF SAID COURT: Now come ____________________________ and wife, _________________________, hereinafter called Petitioners, and respectfully show the Court the Following: I. That heretofore on the _____ day of ________________ , 20 ___ ,your petitioners obtained a Decree of Adoption for the minor child, ___________________________born on_____________in the Country of_____________, in a Court of competent jurisdiction in the country of ______________________, which Decree as a matter of comity is entitled to recognition under the laws of the State of Texas. II. A photostatic copy of the official translation of said Decree of Adoption is attached hereto and made a part hereof for all purposes. III. It is in the best interest and welfare of said child that an appropriate order be made and entered by the Court permitting the issuance of a Birth Certificate for said child by the State Registrar of the Bureau

f Vital Statistics of the State of Texas.

IV. It is in the best interest of said child that his/her name be changed from ____________________________________ to ______________________________________. Wherefore, premises considered, your petitioners pray that this honorable Court make and enter its

rder recognizing said adoption as valid and of full force and effect in the State of Texas, * that the name
f said child be changed to ___________________________________ , and for such other and further
rders as the Court may deem proper to grant.

____________________________________ Attorney for the Petitioners * when applicable

Rev. 7/2009

166.531

SLIDE 39 NO ________________________________ EX PARTE IN THE DISTRICT COURT ________________________ _________ JUDICIAL DISTRICT ET UX _______________ COUNTY, TX ORDER On this the _______ day of _______________ ,20 ___ , came on to be heard the application of ____________________________ and his wife, ______________________ , in the above entitled and numbered cause; and upon hearing thereon, and evidence having been presented to the Court, the Court FINDS that petitioners have heretofore on the _____ day of _________________ , 20 _______ , in a _____________________ Court of competent jurisdiction duly adopted the minor child, _____________________born on ____________________ in the Country of _______________ . The Court further FINDS that all of the prerequisites of the law have been fully complied with by petitioners and that said ___________________________ order of adoption was and is legally valid and of full force and effect under the laws of the United States of America and of the State of Texas. The Court further FINDS that the best interest and welfare of said minor child requires that the following order be entered of record in order that the Birth Certificate may be issued for said child by the State Registrar of the Bureau

f Vital Statistics of the State of Texas.

It is therefore ORDERED, ADJUDGED and DECREED by the Court that the _______________ adoption proceedings by which the petitioners ______________________ and his wife, ________________________, be and the same are hereby recognized by the Court as valid and of full force and effect in the State of Texas; that said adoption is hereby approved and accorded the same validity and dignity as though originally granted by this Court. *It is further ORDERED, ADJUDGED and DECREED that the name of said child be and the same is hereby changed from: ________________________________ to ________ ________________________________. SIGNED THIS _____________ DAY OF _____________________________ , 20 _________ . ________________________________________ Judge Presiding *when applicable

Rev. 7/2009

166.532