STATE OF NEW JERSEY	REPORT OF ADOPTION

INSTRUCTIONS: This form should be completed by either the attorney representing the adoptive parent(s) or the adoption agency having custody of the child. Completion of the adoptive parent(s) information must occur PRIOR to completing information on the infant and natural parents in order to be in compliance with N.J.A.C. 121A-3.7(j)2, which restricts the disclosure of identifying information on the child and the birth parents.

INFORMATION FROM ORIGINAL BIRTH CERTIFICATE
Infant	Name - First	Middle	Last

Sex

Male	Female	Date of Birth	Birthplace-City, County, and State (or Country, if not USA)

Mo.	Day	Yr.
Biological

Mother

Parent A	Full Name (First, Middle, Last) (List name given at birth or on birth certificate)

Biological

Father

Parent B	Full Name (First, Middle, Last) (List name given at birth or on birth certificate)

INFORMATION FOR BIRTH RECORD FOLLOWING ADOPTION
Infant	Name by Adoption - First	Middle	Last

Adopting:

Mother

Parent A	Full Name (First, Middle, Last) (List name given at birth or on birth certificate)

Social Security Number

Current Name, if Different (First. Middle, Last)

Race

Age at Birth of Infant

Date of Birth	State or Country of Birth

Domestic Status

Mo.	Day	Yr.
Residence at Time of Infant’s Birth	City	County	State

Present Address - Street and Number	City, Township, or Boro	County	State	Zip Code

Adopting:

Father

Parent B	Full Name (First, Middle, Last) (List name given at birth or on birth certificate)

Social Security Number

Current Name, if Different (First. Middle, Last)

Race

Age at Birth of Infant

Date of Birth	State or Country of Birth

Domestic Status

Mo.	Day	Yr.
Residence at Time of Infant’s Birth	City	County	State

Present Address - Street and Number	City, Township, or Boro	County	State	Zip Code

ATTORNEY
Name of Attorney (First, Middle, Last)

Telephone No. (Include Area Code)

( )
Firm Name

Mailing Address	City	State	Zip Code

CLERK OF THE COURT
CERTIFICATION:

SEAL OF THE COURT

____________________________________

(Adoption Docket Number)	I hereby certify that the child described above was adopted by the parents cited

in this report on the _______ day of _________________________, 20_____,

as set forth in the decree made in the

__________________________________________________ Court of

__________________________________________________ New Jersey.

______________________________________________________________

(Signature of the Surrogate of the Court)

____________________________________

(Date)

This report must be accompanied by an original certified copy of the adoption decree.

The fee for creating the new Birth Certificate by the State Registrar is $2.00. A certified copy of the Birth Certificate can be ordered for $25.00 and $2.00 for each additional copy required. DO NOT SEND CASH!	MAIL TO:

New Jersey Department of Health

Vital Statistics - Record Modification Unit

P. O. Box 370

Trenton, NJ 08625-0370

REG-44

AUG 15

REG-44, Report of Adoption

REG-44, Report of Adoption, vital statistics, adoption, VS, birth certificate

Elaine White

2003-02-11

ewhite

NJDOH