_____________________________________
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. COUNT
Y 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
ological
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 8/2
015
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 on 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 of 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
office.
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 8/2
015
MAIL APPLICATION FOR
BIRTH AND DEATH RECORD
PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID ID WHEN SENDING IN THE REQUEST.
Make check or money orders payable to: DSHS - Vital Statistics. All funds are deposited directly to the Texas Comptroller of Public Accounts. For any
search of the files where a record is not found, the searching fee is not refundable or transferable.
Birth Certificates
Death Certificates
Type
Cost X
# of
copies=
Total
Type
# of
copies=
Total
Standard Size Long form
$22
Certified Copy (1 copy)
Heirloom Flag Bassinet
$60
Additional Copies
Total (Check or money order payable to DSHS)
Total (Check or money order payable to DSHS)
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 Office of Early Childhood Coordination of Health and Human Services.
IDENTIFY BIRTH OR DEATH RECORD INFORMATION (Part I)
Full Name of
Person
on Record
First Name
Middle Name
Last Name
Date of Birth/Death
Month
Day
Year
Sex
Place of
Birth/Death
City or Town
County
State
Full Name of
Parent 1
First Name
Middle Name
Maiden Name/Last Name
Full Name of
Parent 2
First Name
Middle Name
Maiden Name/Last Name
APPLICANT INFORMATION (Part II)
Applicant Name
Telephone #
Email Address
Full Mailing Address Street Address City State Zip
Relationship to person listed above
Purpose for obtaining this record:
I authorize mailing to the address below. I have verified that the address below will receive my order.
Name of Person Receiving Copies, if Different from Applicant
Mailing Address for Copies, if Different from Applicant
City
State
Zip
AFFIDAVIT OF PERSONAL KNOWLEDGE (MUST BE SIGNED IN PRESENCE OF A NOTARY PUBLIC) (Part III)
STATE OF COUNTY OF Before me on this day appeared _______________________________________
(Applicant name)
now residing at ____________________________________________________________________________________________________________
(Address) (City) (State)
who is related to the person named on Part I as ___________________________________and who on oath deposes and says that the contents of this
affidavit are true and correct. (Relationship)
The applicant presented the following type and number of identification:
Applicant Signature______________________________________________
Sworn to and subscribed before me, this day of , 20 .
(Seal) Signature of Notary Public and Notary ID Number___________________________________________
Typed or Printed Name: _______________________________________________________________
Commission Expires: ________________________________________________________________
Street Address:_____________________________________________________________________
City, State, Zip:_____________________________________________________________________
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 AND SAFETY CODE, CHAPTER 195, SEC. 195.003.
MAIL THIS APPLICATION, PAYMENT AND A VALID PHOTO ID TO:
Texas Vital Records Department of State Health Services
VS-142.3 Rev. 06212016 P.O. Box 12040 Austin, TX 78711-2040
OFFICE USE ONLY
Remit No
By ZZ 708-153
OFFICE USE ONLY