Form DOH422-103 "Birth Parent Request for Original Birth Certificate From Adoption Sealed File" - Washington

Form DOH422-103 is a Washington State Department of Health form also known as the "Birth Parent Request For Original Birth Certificate From Adoption Sealed File". The latest edition of the form was released in May 1, 2014 and is available for digital filing.

Download an up-to-date Form DOH422-103 in PDF-format down below or look it up on the Washington State Department of Health Forms website.

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Download Form DOH422-103 "Birth Parent Request for Original Birth Certificate From Adoption Sealed File" - Washington

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Center for Health Statistics
PO Box 9709
Olympia, Washington 98507-9709
360-236-4300
PublicBirthCorrections@doh.wa.gov
Birth Parent Request for Original Birth Certificate from Adoption Sealed File
☐ I am a Birth Parent requesting a copy of my child’s birth certificate before adoption.
Complete this form with information before the adoption.
Adoptee Name on Birth Certificate_____________________________________________________________
First
Full Middle Name
Last Name
Adoptee Date of Birth__________________ Adoptee place of birth___________________________________
mm/dd/yyyy
City or County
Complete your name as it appears on the child’s original (pre-adoption) birth certificate. Include your
birth name and any other names used either at the time of birth or relinquishment.
Birth Mother/Parent Birth Name_______________________________________________________________
First
Full Middle Name
Birth/Maiden Last Name
Birth Father/Parent Birth Name________________________________________________________________
(if applies)
First
Full Middle Name
Birth/Maiden Last Name
☐ I would like to know if there is a Certified Statement on file stating the adoptees’ desire to be contacted. I
would like the county the adoption was finalized in and the case number. If you request a court appointed
Confidential Intermediary (RCW 26.33.343) in the future, let them know you have this information.
I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true
and correct and I am the birth parent named in the record.
Signature of Birth Parent_______________________________________________Date__________________
Current Legal Name________________________________________________________________________
First
Full Middle Name
Last Name
Current Phone Number (including area code) _ (
___)_________________________________________
Current Email Address ______________________________________________________________________
Current Mailing Address_____________________________________________________________________
PO Box or Street
________________________________________________________________________________________
City
State
Zip Code
This request must include:
A copy of your current photo identification (Driver’s license or State ID card)
A $15 check or money order payable to Department of Health
DOH 422-103 May 2014
Center for Health Statistics
PO Box 9709
Olympia, Washington 98507-9709
360-236-4300
PublicBirthCorrections@doh.wa.gov
Birth Parent Request for Original Birth Certificate from Adoption Sealed File
☐ I am a Birth Parent requesting a copy of my child’s birth certificate before adoption.
Complete this form with information before the adoption.
Adoptee Name on Birth Certificate_____________________________________________________________
First
Full Middle Name
Last Name
Adoptee Date of Birth__________________ Adoptee place of birth___________________________________
mm/dd/yyyy
City or County
Complete your name as it appears on the child’s original (pre-adoption) birth certificate. Include your
birth name and any other names used either at the time of birth or relinquishment.
Birth Mother/Parent Birth Name_______________________________________________________________
First
Full Middle Name
Birth/Maiden Last Name
Birth Father/Parent Birth Name________________________________________________________________
(if applies)
First
Full Middle Name
Birth/Maiden Last Name
☐ I would like to know if there is a Certified Statement on file stating the adoptees’ desire to be contacted. I
would like the county the adoption was finalized in and the case number. If you request a court appointed
Confidential Intermediary (RCW 26.33.343) in the future, let them know you have this information.
I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true
and correct and I am the birth parent named in the record.
Signature of Birth Parent_______________________________________________Date__________________
Current Legal Name________________________________________________________________________
First
Full Middle Name
Last Name
Current Phone Number (including area code) _ (
___)_________________________________________
Current Email Address ______________________________________________________________________
Current Mailing Address_____________________________________________________________________
PO Box or Street
________________________________________________________________________________________
City
State
Zip Code
This request must include:
A copy of your current photo identification (Driver’s license or State ID card)
A $15 check or money order payable to Department of Health
DOH 422-103 May 2014
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