DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 5022 (Rev-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part I, selecting the type of adoption by checking the appropriate box. Enter the child's new name as specified in the decree, including first name, middle name, and last name.
3. In Part II, provide detailed information about both parents post-adoption. Fill in the father's full birth name, date of birth, and state of birth. Repeat this for the mother’s full birth name and current details.
4. Proceed to Part III where you will enter the child's personal data including their full birth name and birthplace. Ensure all fields are completed accurately.
5. Complete Part V regarding fees and mailing information if applicable. Specify payment details for filing and obtaining certified copies of the new birth certificate.
6. Finally, ensure that Parts V and VI are signed by the clerk of court or deputy before submission to ensure compliance with legal requirements.

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