Vital Records Report {VS-37}

STATE OF NEW HAMPSHIRE Department of State Division of Vital Records Administration CONFIDENTIAL Report of City and Town Clerk Relative to an Adoption TYPE OR PRINT ONLY I. CHILD 1. CHILD'S (First) NAME (Middle) (Last) 2. DATE OF BIRTH (Month) (Day) (Year) 3. SEX CHILD 4. LOCATION (City/Town) (County) OF INFORMATION BIRTH AS IT APPEARS BEFORE 5. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND ADOPTION (State/Country) 6. ANCESTRY? (English, French, Puerto Rican, etc.) Specify AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 7. SIBLINGS IN SUBSTITUTE 8. MEMBER SIBLING GROUP ADOPTED 9. PREVIOUS ADOPTIVE PLACEMENT? CARE? TOGETHER? YES NO YES NO YES NO 10. SPECIAL Yes If Yes, Primary Basis: Age Racial/Ethnic Member Sibling Group Medical/Other Disability NEEDS No Other, Specify CHILD If Medical/Other, Check All That Apply Blind/Visually Impaired Deaf/Hard of Hearing Physically Disabled Mental Retardation Emotionally Disturbed Learning Disability Medical Condition Other, Specify: 11. DATE OF ADOPTIVE PLACEMENT (Month) (Day) (Year) 12. AUSPICES OF ADOPTION PUBLIC AGENCY TRIBAL AGENCY OTHER, SPECIFY INDEPENDENT PERSON PRIVATE AGENCY 13. LOCATION OF AGENCY/PERSON (State/Country) II. SUPPORT 14. ADOPTION SUBSIDY YES NO COMPLETE IF 15. SOURCES OF FINANCIAL SUPPORT (CHECK ALL THAT APPLY) STATE/FEDERAL TITLE IV-MONTHLY TITLE IV-E NON-RECURRING STATE ONLY TITLE XVI (SSI) SUPPORT FOR TITLES XIX/XX WITH NO PAYMENT NONE OF ABOVE, PARENTS ONLY CHILD OTHER, SPECIFY BIOLOGICAL 16. FATHER'S NAME (First) (If stated on FATHER (Middle) (Last) 17. DATE (Month) (Day) (Year) OF BIRTH 19. ANCESTRY? (English, French, Puerto Rican, etc.) Specify III. birth certificate) 18. WAS TERMINATION OF PARENTAL RIGHT (Month) (Day) (Year) VOLUNTARY ­ Date of Surrender/Consent NON-VOLUNTARY ­ Date of Termination of Rights NOT APPLICABLE 20. RACE WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLANDER AMERICAN INDIAN/ALASKAN NATIVE UNKNOWN OTHER, SPECIFY 21. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION IV. BIOLOGICAL 22. MOTHER'S MAIDEN SURNAME MOTHER 25. WAS TERMINATION OF PARENTAL RIGHT VOLUNTARY ­ Date of Surrender/Consent NON-VOLUNTARY ­ Date of Termination of Rights NOT APPLICABLE 27. RACE WHITE BLACK CHINESE/JAPANESE AMERICAN INDIAN/ALASKAN NATIVE 28. MARITAL STATUS MARRIED SEPARATED DIVORCED SINGLE 23. DATE OF BIRTH (Month) (Month) (Day) (Year) 24. MOTHER MARRIED AT BIRTH OF CHILD? YES NO (Day) (Year) 26. ANCESTRY? (English, French, Puerto Rican, etc.) Specify OTHER ASIAN/PACIFIC ISLANDER UNKNOWN OTHER, SPECIFY CIVIL UNION WIDOWER CIVIL UNION DISSOLUTION (Continued on Back) PAGE 1 V.S.-37 03/08 American LegalNet, Inc. www.FormsWorkFlow.com V. ADOPTIVE 29. MOTHER's/ (First) PARENT A's MOTHER/ NAME PARENT A 32. RACE (Middle) (Last) 30. MAIDEN NAME (If applicable) 31. DATE (Month) (Day) (Year) OF BIRTH 33. ANCESTRY? (English, French, Puerto Rican, etc.) Specify WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 34. STATE OF BIRTH 35. RESIDENCE (Street Address) AT TIME OF CHILD'S BIRTH: 36. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION (City/Town) (County) (State) 37. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE 39. MAIDEN NAME (If applicable) BIOLOGICAL MOTHER CO-PARENT 40. DATE (Month) (Day) (Year) OF BIRTH VI. ADOPTIVE 38. FATHER's/ (First) FATHER/ PARENT A's NAME PARENT B 41. RACE (Middle) (Last) WHITE BLACK CHINESE/JAPANESE OTHER ASIAN/PACIFIC ISLAND AMERICAN INDIAN/ALASKAN NATIVE OTHER, SPECIFY 43. STATE OF BIRTH 44. RESIDENCE (Street Address) AT TIME OF CHILD'S BIRTH: 45. MARITAL STATUS MARRIED DIVORCED CIVIL UNION SEPARATED SINGLE WIDOWER CIVIL UNION DISSOLUTION 42. ANCESTRY? (English, French, Puerto Rican, etc.) Specify (City/Town) (County) (State) 46. RELATIONSHIP TO CHILD STEP PARENT FOSTER PARENT RELATIVE BIOLOGICAL FATHER CO-PARENT VII. INCOME 47. FAMILY INCOME OF ADOPTIVE PARENTS Under $25,000 $35,000 ­ $44,999 $25,000 ­ $34,999 $45,000 ­ $54,999 $55,000 and over VIII. ADOPTIVE 48. PARENTS WE DO NOT WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION. WE WISH THE BIRTH CERTIFICATE TO BE AMENDED FOLLOWING ADOPTION. A NEW BIRTH CERTIFICATE IS PREPARED FOR THE ADOPTEE AFTER THE ADOPTION IS GRANTED. WE REQUEST THAT THE AMENDED BIRTH RECORD BE PREPARED TO SHOW THE PARENT'S NAMES AND THE NAME OF THE ADOPTEE AS FOLLOWS: (First) (First) (First) 49. MOTHER'S/PARENT A's NAME 50. FATHER'S/PARENT B's NAME (Middle) (Middle) (Middle) (Last) (Last) (Last) CHILD'S 51. ADOPTEE'S NAME ADOPTED NAME 52. CURRENT MAILING ADDRESS (R.F.D., or St. or Box No.) (City/Town) (State) (Zip Code) IX. ADOPTIVE 53. PERSONAL SIGNATURE OF ONE OR BOTH OF THE ADOPTIVE PARENTS PARENTS' MOTHER/PARENT A FATHER/PARENT B SIGNATURE X. PROBATE 54. On the day of , 20 , the COURT OR County, in the State of , FAMILY (Name of Justice or Judge) DIVISION adoption in the case of the child and parents described above, recorded by microfilm or in Vol. , Page , Record No. Date: (Judge, Register, Clerk) NOTE: Court of presiding, passed a decree of Signed and sealed by: 20 When adoption takes place in New Hampshire and the child was born in New Hampshire, the court will forward copies of the adoption report as shown. If the adoptee was not born in New Hampshire, the court will forward copies of the adoption report to the Division of Vital Records Administration, who will forward the report to the respective state of birth. a. Report sent to town clerk of SEAL b. Report sent to Div. of Children & Youth Services c. Report sent to New Hampshire Division of Vital Records Admin. 56. Date forwarded to Div. of Vital Records Admin. Clerk of , 20 , 20 , 20 Date: XI. CITY/TOWN CLERK To be completed by New Hampshire Town/City Clerk of Place of Birth 55. Date received 57. Signed American LegalNet, Inc. www.FormsWorkFlow.com PAGE 2 V.S.-37 03/08