H105 091 rev 4 04 2026

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The document is a Certificate of Adoption from the Commonwealth of Pennsylvania, detailing the process for identifying an original birth record and providing information about the adoptive parents and child. It includes sections for the child's name before adoption, biological parents' names, place and date of birth, details about the adoptive parents, their mailing address, and certification by a county clerk regarding the adoption.

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Click ‘Get Form’ to open the h105 091 rev 4 04 in the editor.
Begin by filling out Part I, which identifies the original birth record. Enter the child's name before adoption, followed by the names of the biological parents.
In Part II, provide details about the place of birth including city, county, and state. Then, fill in the child's full name and date of birth.
Next, complete information regarding adoptive parents. Include their full names, social security numbers, and ages at the time of birth.
Indicate if this is a single-parent adoption and provide the mailing address for adoptive parents as of the time of adoption.
In Part III, enter details about the attorney handling the adoption including their name and contact information.
Finally, certify that all information is accurate by signing in Part IV and providing any necessary dates or case numbers.

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