Mendocino — VS-44

Source: https://www.mendocino.courts.ca.gov/forms_and_filing/forms/VS-44.pdf

COURT REPORT OF ADOPTION NO ERASURES, WHITEOUTS, PHOTOCOPIES, STATE FILE NUMBER OR ALTERATIONS LOCAL REGISTRATION NUMBER

TYPE OR PRINT CLEARLY IN BLACK INK ONLY

PART I The information provided in this section must be the information as it was at birth. Without this data, it may be impossible to prepare a new Certificate of Birth.

1A. NAME OF CHILD—FIRST 1B. MIDDLE 1C. LAST (BIRTH)

FACTS 2. SEX 3. DATE OF BIRTH—MM/DD/CCYY 4. NAME OF PHYSICIAN (OR ATTENDANT, CERTIFIER, OR OTHER PERSON WHO ATTENDED THIS BIRTH)
OF
BIRTH

5A. PLACE OF BIRTH—NAME OF HOSPITAL OR FACILITY 5B. CITY 5C. STATE OR COUNTRY

6A. FULL NAME OF PARENT—FIRST 6B. MIDDLE 6C. LAST (BIRTH) 6D.RELATIONSHIP
MOTHER
FATHER
PARENTS’ PARENT
DATA 7A. FULL NAME OF PARENT—FIRST 7B. MIDDLE 7C. LAST (BIRTH) 7D.RELATIONSHIP
MOTHER
FATHER
PARENT

PART II Adoptive parents must furnish personal information about themselves as it was on the child’s date of birth. This information is used to prepare the new Certificate of Birth. CHECK THE APPROPRIATE BOX: ADOPTIVE PARENT □ BIOLOGICAL PARENT □

8A. NAME OF PARENT—FIRST 8B. MIDDLE 8C. LAST (BIRTH) 8D.RELATIONSHIP
PARENT MOTHER

INFORMATION FATHER PARENT

9. STATE/FOREIGN COUNTRY OF BIRTH 10. DATE OF BIRTH—MM/DD/CCYY

CHECK THE APPROPRIATE BOX: ADOPTIVE PARENT □ BIOLOGICAL PARENT □ PARENT 11A. NAME OF PARENT—FIRST 11B. MIDDLE 11C. LAST (BIRTH) 11D.RELATIONSHIP MOTHER INFORMATION FATHER PARENT

12. STATE/FOREIGN COUNTRY OF BIRTH 13. DATE OF BIRTH—MM/DD/CCYY

14. PLEASE CHECK ONE 15. Do you want the name of the hospital or other facility where birth occurred I want the original birth certificate sealed, and a new birth certificate established. . . . . . . omitted from the new birth certificate as provided for in Section 102645 of the □ Health and Safety Code? (PLEASE CHECK ONE) Pursuant to Health and Safety Code Section 102640, I choose not to have a new birth certificate established. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ YES □ NO □

    16. SIGNATURE OF PARENT VERIFYING DATA IN PART II 17. MAILING ADDRESS OF PARENT VERIFYING DATA IN PART II

VERIFICATION OF PART II ►

18A. NAME OF AGENCY OR DEPARTMENT 18B. MAILING ADDRESS OF AGENCY/DEPARTMENT THAT INVESTIGATED/HANDLED THE ADOPTION AGENCY OR

DEPARTMENT CDSS - Rohnert Park Field Office 101 Golf Course Drive, Suite 250, Rohnert Park, CA 94928

19A. SIGNATURE AND PRINTED NAME OF ATTORNEY 19B. MAILING ADDRESS OF ATTORNEY

ATTORNEY ►

PART III The court clerk must obtain as much information as is available to complete Parts I and II before completing Part III and forwarding the record and Court Order/Final Decree to the State Registrar as required by law.

20. I HEREBY CERTIFY THAT THE INDIVIDUAL DESCRIBED ABOVE WAS ADOPTED BY THE ABOVE NAMED ADOPTIVE PARENTS ON THE __________________________ DAY

OF _____________________, 20, AS SET FORTH IN THE DECREE OF ADOPTION MADE ON THAT DATE IN CASE NUMBER _____________________________

21A. NEW NAME AS SET FORTH IN THE DECREE OF 21B. MIDDLE 21C. LAST
ADOPTION – FIRST

COURT CLERK 22. SIGNATURE AND SEAL OF COURT CLERK BY:

►

23. CLERK IN AND FOR THE COUNTY OF: 24. DATE SIGNED—MM/DD/CCYY 25. DATE PETITION FOR ADOPTION FILED—MM/DD/CCYY

NAME

NAME AND MAILING ADRESS OF PERSON TO ADDRESS—Street and Number CITY, STATE, ZIP CODE DAYTIME TELEPHONE NUMBER WHOM CERTIFIED COPY IS TO BE ( ) SENT

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH - VITAL RECORDS FORM VS 44 (Rev. 1/16)

GENERAL INFORMATION

The Court Clerk shall complete and transmit a court report of adoption to CDPH - Vital Records for each decree of adoption granted by any court in the State of California.

CDPH - Vital Records shall transmit court reports of adoptions for births that occurred in another state, the District of Columbia, any territory of the United States, or Canada to the appropriate registration authority.

The information contained in Part I and Part II of this certificate is required in order to identify and seal the original birth certificate and prepare a new birth certificate. Once the original birth certificate is sealed, it is only available upon order of a Superior Court.

INSTRUCTIONS

The agency or department handling the adoption should fill out Parts I and II, but the Court Clerk may complete any incomplete items in Part I or Part II from the information furnished in the court record.

When requested by the adoptive parents, the CDPH - Vital Records shall not establish a new birth certificate for the child. (Health & Safety Code Section 102640.) The adoptive parents should indicate in Item 14 whether they DO want a new birth certificate established (by checking the “Yes” Box) or whether they DO NOT want a new birth certificate established (by checking the “No” Box).

The adoptive parents may request CDPH – Vital Records to omit the specific name and address of the hospital or other facility where the birth occurred by checking the “Yes” Box in Item 15. (Health & Safety Code Section 102645.)

A deceased spouse of an adopting single parent can be listed on the new birth certificate if both adopting parents were in the home at the time of the initial placement of the child for adoption. Refer to Health & Safety Code Section 102660 for additional requirements.

One of the adopting parents should verify the information in Part II, sign in Item 16, and enter his or her mailing address in Item 17. The name and address of the agency or department and the attorney handling the adoption should be entered in Items 18 and 19.

The applicable fee shall be paid to the Court Clerk at the time of filing the petition in an adoption proceeding for the services required by statute of the State Registrar. (Health & Safety Code Section 103730.)

For cases in which the petition for adoption was filed on or after January 1, 1972, and the individual was

born in California or a foreign country, a certified copy of the new birth record will be furnished without additional fee as provided in Health & Safety Code Section 102710.

For adoptions that occurred prior to January 1, 1972, or in another state, a fee must be submitted for

processing the new birth certificate, which includes one certified copy.

Additional certified copies may be obtained from CDPH – Vital Records, but there is an additional fee for each additional certified copy requested. Please contact CDPH – Vital Records for the current fees, or visit our website at www.cdph.ca.gov. Please do not order additional copies until you have reviewed the original copy for accuracy. The mailing address for CDPH – Vital Records is:

California Department of Public Health – Vital Records

MS 5103 P.O. Box 997410 Sacramento, CA 95899-7410