Fillable CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION State (Florida Department of Health)

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CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION State (Florida Department of Health)

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DH 527, 09/2017, Florida Administrative Code Rule 64V-1.0031 (Obsoletes Previous Editions)
State of Florida
Department of Health - Office of Vital Statistics
CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION
(Important – Read Information and Instructions on reverse side before completion.)
A. INFORMATION REGARDING ORIGINAL STATUS OF CHILD Birth Certificate No. __________________
(If Known)
1a. Child’s Name___________________________________________________________________ 1b. Child’s Sex _________________
First Middle Last
1c. Child’s Date of Birth _______________________ 1d. Child’s Place of Birth _________________________________________________
City State Country
2a. Name of Father/Parent ____________________________________________________________ 2b. Father’s/Parent’s Race ____________
First Middle Last Name Prior to First Marriage (if applicable) Suffix
3a. Name of Mother/Parent ____________________________________________________________ 3b. Mother’s/Parent’s Race ___________
First Middle Last Name Prior to First Marriage (if applicable) Suffix
B. INFORMATION FOR A NEW CERTIFICATE OF BIRTH
1. Child’s Name After Adoption _____________________________________________________________________________________________
(As shown in Final Judgment of Adoption) First Middle Last Suffix
FATHER/PARENT
MOTHER/PARENT
2a. Name: _________________________________________________
First Middle Last Suffix
2b. Name prior to first marriage (if applicable) ____________________
3a. Name: _______________________________________________
First Middle Last Suffix
3b. Name prior to first marriage (if applicable) __________________
2c. Birth Date: __________________________________________
3c. Birth Date: ___________________________________________
2d. Birth Place: __________________________________________
3d. Birth Place: __________________________________________
2e. Race: ________________________________________________
3e. Race: _______________________________________________
2f. Social Security Number: __________________________________
3f. Social Security Number: ________________________________
4. Residence Address of Adoptive Parent(s) at Time of Adoption:
_________________________________________________________________________________________________________________
Street, Apt. No. or Rural Route Number City, Town, or Location County State Zip Code Inside City Limit (Y/N)
5. Mailing address if different from residence address: ___________________________________________________________________________
6. Is this a single parent adoption? ___ Yes ___ No
7. Is this a stepparent or other relative adoption? ____ Yes ___ No If yes, please state relationship _____________________
8. Person completing Part A and B of this Form:
8a. Name: ______________________________________________
Type or Print
8b. Relationship/Title _____________________________________
(If agency, list agency name & License #)
8c. Signature ____________________________________________________________ 8d. Telephone ______________________________
Signature of Person Completing Form Area Code and Number
9a. Attorney/Pro Se Petitioner__________________________________9b.Bar No.__________ 9c.Telephone ____________________________
Type or Print Area Code and Number
9d. Address __________________________________________________________________________________________________________
Street City State Zip Code
“For infant adoptions: If you are interested in obtaining information on Florida’s Health Start Program and potential services available for your
infant, please call the Healthy Baby Hotline at 1-800-45- BABY (1-800-451-2229) and identify yourself as an adoptive parent.”
C. CERTIFICATE OF CLERK OF CIRCUIT COURT Court Docket No._________________________
1. On the _______ day of ______________________, 20_____, the Circuit Court of _________________________ County, _______________
Judge _______________________________ presiding, ordered a decree of adoption in the case of the child and the parents described above.
2a. Signed and Sealed by _________________________________________ 2b. Date ____________________________________________
Clerk of Circuit Court
Clear Form
Print Form
DH 527, 09/2017, Florida Administrative Code Rule 64V-1.0031 (Obsoletes Previous Editions)
INSTRUCTIONS
TYPE OR PRINT IN BLACK INK
(Prompt submission of this statement, when properly completed, will ensure the timely filing of a new birth certificate.)
Pursuant to §. 63.152, Florida Statutes, within 30 days after entry of a judgment of adoption, the clerk of the court, and in agency
adoptions, any child-placing agency licensed by the department, shall prepare a certified statement of the entry for the State Registrar
of Vital Statistics on a form provided by the registrar. A new birth record containing the necessary information supplied by the certificate
shall be issued by the registrar on application of the adoptive parent(s) or the adopted person.
Provide all information. This will ensure timely filing of a new birth certificate. Providing contact information is critical in case contact
with the person completing the form and/or the attorney is needed to obtain additional or clarifying information.
Section B. Complete all information regarding both mother/parent and father/parent regardless of whether a stepparent adoption or two
new parents. This information is required for completion of a new birth certificate. In the case of a stepparent adoption, the information
allows us to verify information already on file.
Fee: Florida law requires a $20.00 fee made payable to “The Office of Vital Statistics” for filing a new birth certificate for a Florida
birth resulting from adoption. This fee includes the issuance of one certification of the new certificate. Certification of the new certificate
cannot be provided prior to the payment of this fee. If the fee is accompanying this statement, please DO NOT send cash. Please send
a check or money order made payable to the Office of Vital Statistics. DH Form 429, Application for Amendment to Florida Birth
Record, should be used when remitting the fee. This will ensure that the new certificate is mailed to the appropriate party as listed on
the application.
If the fee is not remitted at the time of the submission of this statement, the birth record, if the birth occurred in Florida, shall be amended
and the record flagged for collection of the Amendment/Processing fee at the time certification of the new record is requested.
Upon receipt of the report of adoption from a clerk of the court, as heretofore provided for, or upon receipt of a certified copy of a final
decree of adoption, together with all necessary information, the State Registrar shall make and file a new birth certificate. All names
and particulars entered in the new certificate shall refer to the adoptive parents. The original birth record and court documents shall be
sealed only to be opened pursuant to a court order or other provision as may be provided for in Florida law.
Form is also used for adoption of foreign child pursuant to §. 382.017, F.S. which allow the creation of a Certificate of Foreign Birth.
Forms may be obtained through our website below.
OUT OF STATE BIRTHS – ADOPTIONS GRANTED IN FLORIDA: Although birth certificates for these children are not placed
on file in our state, the adoption report sent to our office from the court shall be forwarded to the appropriate registration authority in
the state of birth. DO NOT remit the fee when the birth occurred outside of the State of Florida.
If you have any questions regarding the completion of this form, you may contact the Office of Vital Statistics at (904) 359-6900, ext.
9001.
MAIL THIS FORM WITH PAYMENT AND APPLICATION (DH 429) TO:
DEPARTMENT OF HEALTH
OFFICE OF VITAL STATISTICS
ATTN: ADOPTION UNIT
P.O. BOX 210,
Jacksonville, FL 32231-0042
(Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202)
PLEASE VISIT OUR WEBSITE:
www.floridahealth.gov/certificates
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CERTIFIED STATEMENT OF FINAL DECREE OF ADOPTION State (Florida Department of Health)

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Completed 6 October 2021

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