_____________________________________
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
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