Tennessee > Local County > Shelby > Chancery Court
Certificate Of Adoption - Tennessee
| Certificate Of Adoption Form. This is a Tennessee form and can be used in Chancery Court Shelby Local County . |
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STATE OF TENNESSEE DEPARTMENT OF HEALTH, OFFICE OF VITAL RECORDS CERTIFICATE OF ADOPTION INSTRUCTIONS: USE BLACK INK OR TYPEWRITER TO COMPLETE THIS FORM. DO NOT USE WHITEOUT OR ANY ERASURE. Part I should be completed and signed by the adopting parents. Parts II and III should be completed by attorney, clerk of court, or child placing agency. When the final decree of adoption has been entered, the clerk of court shall enter his/her certification in Part IV, affix the seal of the court, sign, and st th forward to Tennessee Vital Records, Central Services Building, 1 Floor, 421 5 Avenue North, Nashville, TN 37243. If the child was born in another state or U. S. Territory, the office will forward to the proper state. If the child was born in Tennessee, enclose the fee of $30.00 for preparation of a new birth record. The fee entitles applicant to one certified copy of the new birth certificate. Additional copies maybe obtained at the same time for $5.00 each. Make check or money order payable to Tennessee Vital Records. INFORMATION AFTER ADOPTION Full name of child after adoption, as decreed by court. ADOPTIVE FATHER Were you related to this child prior to adoption? Yes No If so, what is your relation? Full Name of Father PART I All items must be completed so that the new birth certificate will show all essential data Date of Birth (Mo/Day/Year) State or Foreign Country of Birth Social Security Number ______________ Full Legal Name of Mother ADOPTIVE MOTHER Were you related to this child prior to adoption? Yes No If so, what is your relation? Maiden Surname of Mother Date of Birth (Mo/Day/Year) State or Foreign Country of Birth Social Security Number Adoptive parents should verify all personal data for accuracy and sign this form before Part II is completed. ______________ Adopting mother's mailing address at time of the adoption (Street, Number, City, State and Zip Code) County of Residence I have reviewed the information entered in Part I and verify that it is accurate. Note: When the spouse of the child's biological parent (i.e. child's stepparent) is the adopting parent, both the stepparent and biological parent should complete Part I. Mother's Signature Father's Signature Date Date Do you want a new birth certificate prepared? YES NO. If a single parent adoption: Do you want the word "Adoption" to be entered in the space provided for the other parent? YES NO INFORMATION ABOUT CHILD BEFORE ADOPTION PART II This information is used to locate the child's original birth record. If the child was previously adopted, please give the adoptive parents' names. Name of Child at Birth Date of Birth (Mo/Day/Year) Full Maiden Name of Mother Sex Male Place of Birth (Hospital, City, State) Birth Certificate No. (if known) Female Full Name of Father Please include $30.00 fee to process request, additional copies maybe obtained at the same time for $5.00 each. Make check or money order payable to TENNESSEE VITAL RECORDS. Enter the address to which the birth certificate should be sent. PART III MAILING ADDRESS AND TELEPHONE NUMBER NAME: ADDRESS: CITY, STATE, ZIP CODE: DAYTIME PHONE NUMBER: ( ) Docket Number Date of Decree CERTIFICATION OF CLERK OF COURT State of County of TENNESSEE PART IV COURT SEAL I hereby certify that there was a final decree of adoption entered by this the day, , in the year of is deemed to be the lawful child of the adoptive parents identified in Part I. Court of this county on , which adjudged that the child named in Part I Clerk's Signature Date SEND THIS FORM AND REQUIRED FEE TO: PH-1248 (rev 11/2008) American LegalNet, Inc. www.FormsWorkFlow.com RDA 1399 Tennessee Vital Records, Central Services Building, 1st Floor, 421 5th Avenue North, Nashville, TN 37243 PH-1248 (rev 11/2008) American LegalNet, Inc. www.FormsWorkFlow.com RDA 1399
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