Office of Vital Records and Statistics
4150 Technology Way, Suite 104 ● Carson City, Nevada 89706
775-684-4242 ● Fax 775-684-4156 ● dpbh.nv.gov/Vitalrecords
Page 1 of 2
REPORT OF ADOPTION
P
ART
1
-
A
DOPTEE
’
S
I
NFORMATION
The information in this section must be given as it was before the adoption, if known. Without this information it may be impossible to locate and amend the adoptee’s
birth record.
Adoptee
Adoptee First Name
Adoptee Middle Name
Adoptee Last Name
Adoptee Date of Birth
Adoptee Place of Birth (City or Hospital)
Adoptee State of Birth
Adoptee Sex
Birth Parents
Birth Parent #1 First Name
Birth Parent #1 Middle Name
Birth Parent #1 Last - Maiden Name
Birth Parent #2 First Name
Birth Parent #2 Middle Name
Birth Parent #2 Last – Maiden Name
P
ART
2
-
A
DOPTIVE
P
ARENTS
’
I
NFORMATION
Adopting parents must furnish the following information on themselves. The information will be used to prepare a new birth certificate. PLEASE DO NOT USE
INITIALS.
P
ARENT
(1) I
NFORMATION
Check the Appropriate Box: ☐ Adoptive Parent ☐ Biological Parent
First Name
Middle Name
Last Name
Last Name - Prior to First Marriage
Date of Birth
Place of Birth (State or Country)
Current Occupation (type of work - not employer)
Social Security Number
Residence at the
Time of Adoptee’s
Birth
State
County
City or Town
Street Address
ZIP Code
Inside City Limits?
Yes No
Current Mailing Address (Street, City, State & ZIP)
Telephone Number
P
ARENT
(2)
I
NFORMATION
Check the Appropriate Box: ☐ Adoptive Parent ☐ Biological Parent
First Name
Middle
Last
Last Name - Prior to First Marriage
Date of Birth
Place of Birth (
State
or
Country
)
Current Occupation
(type of work - not employer)
Social Security Number
SIGNATURE OF PARENT VERIFYING INFORMATION IN PART 2 IS CORRECT
First Name (print)
Last Name (print)
Signature of Parent Verifying Information
ATTORNEY OF RECORD INFORMATION
First Name
Last Name
Phone Number
Mailing Address (Street, City, State & ZIP)
P
ART
3
–
C
OURT
C
LERK
’
S
C
ERTIFICATION
The clerk of the court requires all available information in Parts 1 and 2 above, before completing and certifying Part 3.
I hereby certify that the child identified above was adopted by the above-named parent(s) on the
day of
, 20
and is now to bear the name of
(Do Not Use Initials) as set forth in
First
Middle
Last
the decree of adoption made on that day in case number
in
County, Nevada.
Signature and Seal of County Clerk
Date Signed
P
ART
4
–
M
AILING
C
OMPLETED
N
EW
B
IRTH
C
ERTIFICATES
(REQUIRED):
When completed, the new birth certificate will be mailed to the following person and address:
Addressee’s First Name
Addressee’s Last Name
Addressee’s Mailing Address or P.O. Box
State
ZIP
Office of Vital Records and Statistics
4150 Technology Way, Suite 104 ● Carson City, Nevada 89706
775-684-4242 ● Fax 775-684-4156 ● dpbh.nv.gov/Vitalrecords
Page 2 of 2
Instructions
Please submit all necessary documentation as detailed below with payment to process your adoption request.
Part 1: Adoptee’s Information
The information in this section must be given as it was at the time of birth (before the adoption) to locate the birth record.
• Name of Adoptee at the time of birth – No Initials
• Adoptee’s Birth Information
• Birth Parents’ Information – No Initials
Part 2: Adopting Parents’ Information
Please enter the adoptive parents’ information.
• Do not use initials as this will cause your paperwork to be returned.
• Enter the last name prior to first marriage. Please do not leave it blank.
• In the Occupation field, enter the type of work – not the employer of the adoptive parents. Without the adoptive
parents’ occupational data, the birth parents’ occupations will remain on the birth record.
• Enter current complete mailing address including city, state and ZIP code.
• Enter Parent 1’s full address at the time of the Adoptee’s birth.
• Signature of parent verifying the information in Part 2 is correct.
• Attorney of Record’s information. This is the person that is assisting with the adoption.
Part 3: Court Clerk’s Authorization
The court clerk will complete Part 3.
Part 4: Address to Return Completed Certificate (Required)
The new birth certificate will be mailed to the current address listed in Part 2 unless a different address is requested in Part
4. Please allow four to six weeks (4-6) weeks to process your request.
Required Documentation (Must be included with the Report of Adoption):
• For adoptees born and adopted in Nevada and/or in another state, submit each of the following:
Report of Adoption and certificate by the court clerk
Certified U.S. District Court Order Decree of Adoption
Proper Filing Fee (see below)
• For adoptees born in a foreign country, other than Canada and adopted in Nevada, submit each of the following:
Report of Adoption
Certified U.S. District Court Order Decree of Adoption
Evidence the adoptive parents are Nevada Residents such as an original utility bill.
Proof the adoptee is a U.S. Citizen.
Proper Filing Fee
General Information
Common Reasons for Rejections: Cross-outs, white outs, corrections or lack of payment
Fees: Filing Fee $45.00 (Includes one (1) certified copy of the amended birth record.)
Additional Copies $25.00 each.
Mail Documents and Fees to:
Office of Vital Records & Statistics
Attn: Adoptions
4150 Technology Way, Ste 104
Carson City, Nevada 89706
For More Information: Visit the website at http://dpbh.nv.gov/Programs/VitalRecords/
or call the Office of Vital
Records and Statistics at (775) 684-4242.
(Revised 2/06/2020)
