Form ADPH-HS84FB "Application to Prepare a Certificate of Foreign Birth" - Alabama

What Is Form ADPH-HS84FB?

This is a legal form that was released by the Alabama Department of Public Health - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2012;
  • The latest edition provided by the Alabama Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form ADPH-HS84FB by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form ADPH-HS84FB "Application to Prepare a Certificate of Foreign Birth" - Alabama

Download PDF

Fill PDF online

Rate (4.4 / 5) 42 votes
APPLICATION TO PREPARE A CERTIFICATE OF FOREIGN BIRTH
Effective January 1, 2013, the Center for Health Statistics may prepare and register a Certificate of Foreign Birth upon receipt of a request
from an adoptive parent or an adopted individual 19 years of age or older. A Certificate of Foreign Birth may be put on file for a child who
has automatically acquired United States citizenship following a foreign adoption and who possesses a Certificate of Citizenship in
accordance with the Child Citizenship Act. Upon receipt of the required documentation and the appropriate fee, the Center for Health
Statistics will prepare a Certificate of Foreign Birth showing the child’s new name and the name(s) of the new parent(s). All of the following
documents must be provided in order to prepare the Certificate of Foreign Birth:
The child’s Certificate of Citizenship;
A certified copy of the child’s foreign birth certificate and certified English translation;
The original documents related to the foreign adoption certified by the United States Embassy abroad and certified English
translation;
The Social Security card of the child;
A valid government issued picture identification of parent or parents, such as a passport, driver’s license, or military
identification;
Proof of current residency of the parent or parents in the State of Alabama. Submit at least one of the following:
Valid Alabama driver’s license;
Current utility bill;
o
o
Current Alabama tax return;
Another record that confirms Alabama residency.
o
o
Current Alabama property tax bill;
o
The fee to prepare the Certificate of Foreign Birth is $25.00 which includes one certified copy of the new record. Additional copies of the
same record ordered at the same time are $6.00 each. There is an additional fee of $15.00 to expedite a request. Make check or money
order payable to “State Board of Health.”
Complete and send the application below with the required
FEES ARE NOT REFUNDABLE.
documents and appropriate fee to:
Center for Health Statistics
Adoption Specialist
P.O. Box 5625
Montgomery, AL 36103-5625
If you have additional questions, call 334.206.2644. NOTE: If the child was born in another country to a U.S. citizen, contact the U.S.
Department of State at 202.955.0307 or visit the website: www.travel.state.gov.
You must answer the following question: Is there a certificate of foreign birth on file or action pending for this child in another
9
9
state?
YES
NO
Full Name of Child on New Birth Certificate
First
Middle
Last
Date of Birth of Child
City and Country of Birth
Sex
Full Maiden Name of Adoptive Mother
First
Middle
Last
Date of Birth of Adoptive Mother
State of Birth of Adoptive Mother
(If not in U.S.A., name country)
Full Name of Adoptive Father
First
Middle
Last
Date of Birth of Adoptive Father
State of Birth of Adoptive Father
(If not in U.S.A., name country)
APPLICANT SECTION
Amount
$ ___________
(THIS SECTION MUST BE COMPLETED)
__________
Number of Copies:
Enclosed
Anyone providing false information or falsely applying for a record is subject to a penalty upon conviction of up to three months
in the county jail or a fine of up to $500. Code of Ala. 1975, § 13A-10-109. By signing, you are certifying you have a legal right to
the record requested and all of the information provided on this form is true and correct.
Signature
Date
         
         
Printed Name
Day Time Phone
         
Address
         
         
City
State
Zip
ADPH-HS 84FB/REV. 11/2012
APPLICATION TO PREPARE A CERTIFICATE OF FOREIGN BIRTH
Effective January 1, 2013, the Center for Health Statistics may prepare and register a Certificate of Foreign Birth upon receipt of a request
from an adoptive parent or an adopted individual 19 years of age or older. A Certificate of Foreign Birth may be put on file for a child who
has automatically acquired United States citizenship following a foreign adoption and who possesses a Certificate of Citizenship in
accordance with the Child Citizenship Act. Upon receipt of the required documentation and the appropriate fee, the Center for Health
Statistics will prepare a Certificate of Foreign Birth showing the child’s new name and the name(s) of the new parent(s). All of the following
documents must be provided in order to prepare the Certificate of Foreign Birth:
The child’s Certificate of Citizenship;
A certified copy of the child’s foreign birth certificate and certified English translation;
The original documents related to the foreign adoption certified by the United States Embassy abroad and certified English
translation;
The Social Security card of the child;
A valid government issued picture identification of parent or parents, such as a passport, driver’s license, or military
identification;
Proof of current residency of the parent or parents in the State of Alabama. Submit at least one of the following:
Valid Alabama driver’s license;
Current utility bill;
o
o
Current Alabama tax return;
Another record that confirms Alabama residency.
o
o
Current Alabama property tax bill;
o
The fee to prepare the Certificate of Foreign Birth is $25.00 which includes one certified copy of the new record. Additional copies of the
same record ordered at the same time are $6.00 each. There is an additional fee of $15.00 to expedite a request. Make check or money
order payable to “State Board of Health.”
Complete and send the application below with the required
FEES ARE NOT REFUNDABLE.
documents and appropriate fee to:
Center for Health Statistics
Adoption Specialist
P.O. Box 5625
Montgomery, AL 36103-5625
If you have additional questions, call 334.206.2644. NOTE: If the child was born in another country to a U.S. citizen, contact the U.S.
Department of State at 202.955.0307 or visit the website: www.travel.state.gov.
You must answer the following question: Is there a certificate of foreign birth on file or action pending for this child in another
9
9
state?
YES
NO
Full Name of Child on New Birth Certificate
First
Middle
Last
Date of Birth of Child
City and Country of Birth
Sex
Full Maiden Name of Adoptive Mother
First
Middle
Last
Date of Birth of Adoptive Mother
State of Birth of Adoptive Mother
(If not in U.S.A., name country)
Full Name of Adoptive Father
First
Middle
Last
Date of Birth of Adoptive Father
State of Birth of Adoptive Father
(If not in U.S.A., name country)
APPLICANT SECTION
Amount
$ ___________
(THIS SECTION MUST BE COMPLETED)
__________
Number of Copies:
Enclosed
Anyone providing false information or falsely applying for a record is subject to a penalty upon conviction of up to three months
in the county jail or a fine of up to $500. Code of Ala. 1975, § 13A-10-109. By signing, you are certifying you have a legal right to
the record requested and all of the information provided on this form is true and correct.
Signature
Date
         
         
Printed Name
Day Time Phone
         
Address
         
         
City
State
Zip
ADPH-HS 84FB/REV. 11/2012