State…

                                                               State of Nevada
                                                 REPORT OF ADOPTION
PART I The information in this section must be given as it was before this adoption. Without this data it may be
                impossible to locate and amend this child's birth record.
                                First                                         Middle                                          Last
Name of
 Child

Date of Birth                                                Place of birth (City or Hospital)                        State of Birth             Sex



Maiden Name of Mother           (First)                          (Middle)                         (Last)



Name of Father                   (First)                         (Middle)                         (Last)



PART II Adopting parents must furnish the following information concerning themselves. The information will be
                used to prepare a new birth certificate. PLEASE DO NOT USE INITIALS.

Check Appropriate Box      Mother's Present Name- First          Middle                          Last                           Maiden Last Name
 Adoptive Mother
 Natural Mother
Mother's Date of Birth          Mother's Place of Birth (State or            Mother's Current Occupation           Mother's Social Security Number
                                Country)


                                State               County                                          City or Town

 Mother' Residence at the
 time of this child's birth     Street Address                                                      Zip Code                         Inside City Limits?
                                                                                                                                     (Yes or No)

  Check Appropriate Box         Father's Name- First                        Middle                                 Last
    Adoptive Father
     Natural Father
Father's Date of Birth          Father's Place of Birth (State or            Father's Current Occupation           Father's Social Security Number
                                Country)


Signature of Parent verifying data in Part II       Current Mailing Address                                               Telephone Number



Name and Mailing Address of Attorney of Record                                                                            Telephone Number




PART III         The clerk of the court must require as much of the information as is available in Parts I and II, above,
                 before completing and certifying Part III.


I hereby certify that the child identified above was adopted by the above named parent(s) on the ______th day of ___________,

20____ and is now to bear the name of ______________________ ______________________ ______________________ 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 _____________________

(Rev. 07-04)
                     MAILING INSTRUCTIONS

For children born and adopted in Nevada please submit a certified
Nevada Report of Adoption with an uncertified decree (photocopy) or
a certified decree of adoption with the Nevada Report of Adoption
uncertified

For children born in Nevada but adopted in another state, please
submit a certified decree of adoption with the Nevada Report of
Adoption uncertified.

                                   FEES

Please remit $20.00 filing fee per NRS 440.700. This provides one
certified copy of the amended birth record. Additional copies are
$13.00 each.

Please mail your documents and fees to

                    Nevada State Office of Vital Records
                     4150 Technology Way, Suite 104
                       Carson City Nevada 89706

Please allow 4-5 weeks to process your request. Should you have any
questions please contact our office at (775) 684-4242.

When completed, the new birth certificate is to be mailed
                   to the following



                                     Name



                           Street Address or P.O. Box



             City                  State                Zip Code