Certificate of Adoption Division of Vital Records

PART I	This information in this section must be given as it was before adoption. Without this data it may be impossible to prepare an amended certificate of birth for this child.

FACTS OF BIRTH	NAME OF CHILD - First Name

Middle Name

Last Name

Date of Birth

Sex

Race

County of Birth

State or Foreign Country of Birth

NATURAL PARENTS DATA	Maiden name of Mother - First Name

Middle Name

Last Name (Maiden Surname)

Name of Father - First Name

Middle Name

Last Name

VERIFICATION OF PART I	Signature of person verifying data in Part I	Authorization (attorney, clerk of court, agency director, other (specify)

PART II	Adopting parents must furnish the following information concerning themselves as it was at the date of birth of the above child. This information is used in preparation of the amended certificate of birth.

MOTHER	Mother's Current Legal Name - First Name

Middle Name

Last	Suffix

Maiden Name of Mother - First Name

Middle Name

Last Name (Maiden Surname)

Date of Birth - Month, Day, Year

Birthplace (State of Foreign Country)

Color or Race

Residence - City or Town

County

State

FATHER	Name of Father - First Name

Middle Name

Last Name

Date of Birth - Month, Day, Year

Birthplace (State or Foreign Country)

Color or Race

Occupation

Kind of Business or Industry

VERIFICATION OF

PART II	Signature:	NOTE:	Where the spouse of the child's natural parent (i.e. the child's stepparent) is the adopting parent, for the purpose of completing this form, both the stepparent and the natural parent will be considered the adopting parents.
Mother
Father
Prior relationship between adopting parent(s) and adopted child:
MOTHER:
Stepmother
Grandmother
Natural Mother
Aunt
Other (specify):
FATHER:
Stepfather
Grandfather
Natural Father
Uncle
Other (specify):	_________________
AGENCY OR DEPARTMENT	Name and mailing address of agency or department which investigated or handled case.

ATTORNEY	Name and mailing address of Attorney

PART III

DOMESTICATION OF FOREIGN ADOPTION	To Be Completed by the Clerk of Court

I hereby certify that the foreign adoption of the child by the parents named in Part II above and described in the order made on the	and recorded in Judgement Roll or Docket No.	was domesticated and is now to bear the name of	as set forth in the order. Signature and Seal of Clerk of Court	Date signed	Clerk of Court in and for the County of	State of

I hereby certify that the foreign adoption of the child by the parents named in Part II above and described in the order made on the______	_____and recorded in Judgment Roll or Docket No.____	was domesticated and is now to bear the name of	_________________________as set forth in the order.

Signature and Seal of Clerk of Court	____________________________Date signed	___________________________________

Clerk of Court in and for the County of __	____________________State of	___________________

PART IV

SC ADOPTION	I hereby certify that the child described in the decree of adoption made on the ______________ and recorded in Judgment Roll or Docket No.	was adopted by the parent(s) named in Part II and is now to bear the name of	as set forth in the order.

Signature and Seal of Clerk of Court	Date signed

Clerk of Court in and for the County of	State of

PART V	When birth occurred in a state other than South Carolina the State Registrar shall forward this certificate to the proper

official in the state of birth.

Certification of

S.C. Dept. of Health & Env. Control	I hereby certify that this report of adoption was received on the	Signature	Title
DHEC 0671 (Rev. 02/2005)

2013-10-31