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ADOPTION INFORMATION FORM (Read Information …

COMMONWEALTH OF KENTUCKY CABINET FOR HEALTH AND FAMILY SERVICES REGISTRAR OF VITAL STATISTICS ADOPTION INFORMATION form ( read INFORMATION Below Before Completing) A. INFORMATION REGARDING ORIGINAL STATUS OF CHILD Original Name of Child _____ State File No. _____ Sex _____ Date of Birth _____ Place of Birth _____ (City) (County) (State) Name of Father _____ Race _____ Maiden Name of Mother _____ Race _____ B. INFORMATION REGARDING ADOPTIVE PARENTS FOR NEW CERTIFICATE OF BIRTH (All INFORMATION requested below MUST be provided, or a new birth certificate cannot be completed for filing.)

(4) Not later than the fifteenth day of each calendar month or more frequently, the clerk of the court shall forward to the state registrar reports of decrees of adoption, annulments of adoption, and amendments of decrees of adoption which were entered in the preceding month, together with such related reports as the state registrar will require.

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