State of
A
rizona
Arizona Department of Health Services - Bureau of Vital Records
Certificate of A
dop
t
ion
THIS IS A PERMANENT RECORD - PLEASE TYPE OR PRINT
O
N
LY
St
a
t
e
F
ile Number
PART I: Birth information needed to locate the current birth certificate on file
I
den
t
i
f
ica
t
ion
of Child and
Place of
B
ir
t
h
Name of Child at Birth A. First B. Middle C. Last D. Suffix
1
Sex
2
Date of Birth - Month, Day, Year
3
Place of Birth A. Town or City B. County C. State (Include Zip Code)
4
Name of Hospital/facility
5
Natural
Parents
Name of Father/Parent A. First B. Middle C. Last Name D. Suffix F. Date of Birth - Month, Day, Year
6
Name of Mother/Parent A. First B. Middle C. Last Name Prior to First Marriage D. Suffix F. Date of Birth - Month, Day, Year
7
I
nves
t
iga
t
ive
A
gency
Name of Agency
8
Agency Address
9
Attorney o
f
Record
Attorney(s) of Record (if applicable)
10
Attorney(s) of Record - Address Date
11
Data
f
or
Statistical Use
Total No. of Children
in this Adoption
12
Type of Adoption
Step-Parent Grand Parent Other Relative Non Relative
13
PART II: Information about the adoption – The adoptive parents are responsible for reviewing the information in this section to confirm the information provided
in each field is accurate before affixing their dated signature.
Father/Parent
Adoptive
Natural
Name A. First B. Middle C. Last Suffix
14
Date of Birth - Month, Day, Year
15
Place of Birth - State or Country
16
Social Security Number
17
Mother/Parent
Adoptive
Natural
Name A. First B. Middle C. Last Name Prior to First Marriage
18
Date of Birth - Month, Day, Year
19
Place of Birth - State or Country
20
Social Security Number
21
Residence of Adoptive Mother/Parent at Time of Child's Birth (Street Address, Town, County, State, Zip)
22
Current Address (Include Zip Code)
23
Parent's
Verification
I attest the information provided above is accurate, true and valid to
the best of my knowledge.
Adoptive Mother’s/Parent’s Signature
24
Date Signed
25
Adoptive Father’s/Parent’s Signature
26
Date Signed
27
Omit Name of Hospital, Facility, or Street Address
Where Birth Occurred Yes No
28
Do you want the birth record amended?
Yes
No
29
PART III: When the final order of adoption is granted, the Clerk of Superior Court must complete the following section, and forward the report to the Bureau of
Vital Records. By signing this document, the court is certifying the information contained in this document is accurate.
A Final Order of Adoption was Granted in the Superior Court on
Mail to:
____________________________________20__________________ in Case No.________________________
Bureau of Vital Records
Judge ____________________________________________________________________________Presiding PO BOX 6018
Clerk 30 Phoenix, AZ 85005
Of Court By Date Signed Clerk for County of
Information
31 32 33
The Name of the Child as Set Forth in the Adoption Order shall be
First Middle Last Suffix
34
PART IV:
In the event there is an error on the Certificate of Adoption the Bureau of Vital Records will contact the adoptee.
NOT TO BE FILED WITH THE CLERK OF THE COURT. PLEASE FORWARD THIS DOCUMENT TO THE BUREAU OF VITAL RECORDS.
Adoptee
Information
Adoptee Address (include Zip Code)
35
Adoptee Phone Number
36
