Get KS VS-220 2021-2024

REPORT OF ADOPTION 1. CHILD S NAME AFTER ADOPTION First Middle Last CHILD / 2. MOTHER S PRESENT NAME First Middle Last ADOPTING PARENTS 2b. When a Report of Adoption is received the Office of Vital Statistics contacts the attorney or adoptive parents to obtain one or both parents signatures on the supplemental birth certificate. If the child being adopted was born outside the state of Kansas the report of adoption will be forwarded to the appropriate state vital statistics office by the Kansas Office of Vital Statistics. This Report of Adoption and the original Certificate of Live Birth will be sealed and will be opened only by court order or by written request of the adopted person if of legal age as directed by KSA 65-2423. MOTHER S NAME PRIOR TO FIRST MARRIAGE First Middle Last I hereby certify that the child identified above was adopted by the above named parent s on the OF DISTRICT day of in the District Court of County KS. day month year COURT Case Number Signature of District Court Judge Place court seal here required Kansas Department of Health and Environment Bureau of Epidemiology and Public Health Informatics Office of Vital Statistics 1000 SW Jackson Street Suite 120 Topeka Kansas 66612-2221 785 296-1436 Date Form VS-220 Revised 03-2011 For court use only District Court Information Case number Date petition was filed Date of final decree Child s Name NATURAL name of person adopted Name of person after ADOPTION Date Order of Adoption was sent to the Office of Vital Statistics in Topeka Kansas INSTRUCTIONS Please enter the information requested for each item. This is a permanent record. All information must be typed. Kansas District Courts are required by state statute KSA 59-2104 to report adoptions to the Office of Vital Statistics. BIRTH DATE MM/DD/YYYY 2a* MOTHER S LAST NAME PRIOR TO FIRST MARRIAGE 2c* BIRTH PLACE State 2d. RACE 2e. SOCIAL SECURITY NUMBER 2f* RESIDENCE At time of child s birth. This information is needed to Prepare a New Birth Certificate. State Street Number County City/Town Zip Inside City Limits Yes No 3. FATHER S NAME First Middle Last 3a* BIRTH DATE MM/DD/YYYY 3b. BIRTH PLACE State 3c* RACE 4. CURRENT MAILING ADDRESS OF PARENT S 5a* Was 5c* Did child born in a foreign country Yes go to 5b. the adoption occur in a foreign country No go to 5c* 5d. If 5b. Was the child born to U*S* Citizens yes are the adopting parents residents of Kansas 6. TYPE OF ADOPTION select one STEP-PARENT ADOPTION TRADITIONAL ADOPTION SINGLE-PARENT ADOPTION 7. Name and Mailing Address of Attorney ATTORNEY 7a* Email and Telephone Number Name Street City - INFORMATION ON ORIGINAL BIRTH CERTIFICATE 8a* CHILD S BIRTH DATE MM/DD/YYYY 8b. CHILD S SEX MALE 8c* BIRTH CERTIFICATE NUMBER if known FEMALE 9. CHILD S BIRTH PLACE County/Province State/Country 10. MOTHER S NAME PRIOR TO FIRST MARRIAGE First Middle Last I hereby certify that the child identified above was adopted by the above named parent s on the OF DISTRICT day of in the District Court of County KS* day month year COURT Case Number Signature of District Court Judge Place court seal here required Kansas Department of Health and Environment Bureau of Epidemiology and Public Health Informatics Office of Vital Statistics 1000 SW Jackson Street Suite 120 Topeka Kansas 66612-2221 785 296-1436 Date Form VS-220 Revised 03-2011 For court use only District Court Information Case number Date petition was filed Date of final decree Child s Name NATURAL name of person adopted Name of person after ADOPTION Date Order of Adoption was sent to the Office of Vital Statistics in Topeka Kansas INSTRUCTIONS Please enter the information requested for each item* This is a permanent record.