Form ADPH-HS-103 "Application to Request an Alabama Birth Certificate After Surrogate Birth" - Alabama

What Is Form ADPH-HS-103?

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 February 7, 2020;
  • 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 printable version of Form ADPH-HS-103 by clicking the link below or browse more documents and templates provided by the Alabama Department of Public Health.

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Download Form ADPH-HS-103 "Application to Request an Alabama Birth Certificate After Surrogate Birth" - Alabama

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APPLICATION TO REQUEST AN ALABAMA BIRTH CERTIFICATE AFTER SURROGATE BIRTH
When a surrogate birth occurs in Alabama, the Center for Health Statistics must be presented an original, final court order
determining the child’s legal parentage. Upon receipt of the final court order providing the required information, the Center for
Health Statistics will prepare a new birth certificate for the child showing the child’s name and the name(s) of the legal parent(s).
The fee to prepare the new certificate of 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.” Do not send cash. Fees are non-refundable.
Valid identification must be submitted with a request for a new Alabama birth certificate. See the identification
requirements on the reverse side. Complete the application below and send with the valid identification and appropriate fee to:
Center for Health Statistics
Attn: Parentage Clerk
P.O. Box 5625
Montgomery, Alabama 36103-5625
To reduce delay in certificate issuance, the completed application, valid identification and fee may be submitted to the Center for
Health Statistics while the final court order is in process. However, the new birth certificate cannot be created before the final
court order is received by this office. If an Apostille or Exemplified copy is required with the birth certificate, or if you have
additional questions, call 334.206.2637 or visit our website at www.alabamapublichealth.gov/vitalrecords.
FULL NAME OF CHILD _________________________________________________________________________________________________________
First
Middle
Last
COUNTY OF BIRTH ______________________________________ HOSPITAL ____________________________________________________________
DATE (OR ESTIMATED DATE) OF BIRTH _________________________________________________ SEX ____________________________________
FULL NAME OF LEGAL MOTHER/PARENT ________________________________________________________________________________________
First
Middle
Maiden Last
Current Last
RESIDENCE STATE (OR FOREIGN COUNTRY) OF LEGAL MOTHER/PARENT ___________________________________________________________
RESIDENCE COUNTY (OR FOREIGN PROVINCE) OF LEGAL MOTHER/PARENT _________________________________________________________
FULL NAME OF LEGAL FATHER/PARENT _________________________________________________________________________________________
First
Middle
Maiden Last
Current Last
APPLICANT SECTION
Amount
(THIS SECTION MUST BE COMPLETED)
______________
$ ________________
Number of Copies
Enclosed
Valid identification must be submitted with a request for a new birth certificate. Anyone 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 Alabama 1975,
§ 13A-10-109). By signing, you are certifying you have a legal right to the record requested.
Your Signature ______________________________________________________________________ Date _____________________________________
Print Your Name ______________________________________________________________________________________________________________
Your Relationship to Child _______________________________________________________________________________________________________
Mail to Name (if Different from You) _______________________________________________________________________________________________
__________________________________________________________________________________________________
Mailing Address
City _________________________________ State _____________ Zip _________________ Daytime Phone (_________) _________________________
I allow the following individual to receive the certificate(s) ______________________________________________________________________________
ADPH-HS-103 – 2/7/2020
APPLICATION TO REQUEST AN ALABAMA BIRTH CERTIFICATE AFTER SURROGATE BIRTH
When a surrogate birth occurs in Alabama, the Center for Health Statistics must be presented an original, final court order
determining the child’s legal parentage. Upon receipt of the final court order providing the required information, the Center for
Health Statistics will prepare a new birth certificate for the child showing the child’s name and the name(s) of the legal parent(s).
The fee to prepare the new certificate of 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.” Do not send cash. Fees are non-refundable.
Valid identification must be submitted with a request for a new Alabama birth certificate. See the identification
requirements on the reverse side. Complete the application below and send with the valid identification and appropriate fee to:
Center for Health Statistics
Attn: Parentage Clerk
P.O. Box 5625
Montgomery, Alabama 36103-5625
To reduce delay in certificate issuance, the completed application, valid identification and fee may be submitted to the Center for
Health Statistics while the final court order is in process. However, the new birth certificate cannot be created before the final
court order is received by this office. If an Apostille or Exemplified copy is required with the birth certificate, or if you have
additional questions, call 334.206.2637 or visit our website at www.alabamapublichealth.gov/vitalrecords.
FULL NAME OF CHILD _________________________________________________________________________________________________________
First
Middle
Last
COUNTY OF BIRTH ______________________________________ HOSPITAL ____________________________________________________________
DATE (OR ESTIMATED DATE) OF BIRTH _________________________________________________ SEX ____________________________________
FULL NAME OF LEGAL MOTHER/PARENT ________________________________________________________________________________________
First
Middle
Maiden Last
Current Last
RESIDENCE STATE (OR FOREIGN COUNTRY) OF LEGAL MOTHER/PARENT ___________________________________________________________
RESIDENCE COUNTY (OR FOREIGN PROVINCE) OF LEGAL MOTHER/PARENT _________________________________________________________
FULL NAME OF LEGAL FATHER/PARENT _________________________________________________________________________________________
First
Middle
Maiden Last
Current Last
APPLICANT SECTION
Amount
(THIS SECTION MUST BE COMPLETED)
______________
$ ________________
Number of Copies
Enclosed
Valid identification must be submitted with a request for a new birth certificate. Anyone 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 Alabama 1975,
§ 13A-10-109). By signing, you are certifying you have a legal right to the record requested.
Your Signature ______________________________________________________________________ Date _____________________________________
Print Your Name ______________________________________________________________________________________________________________
Your Relationship to Child _______________________________________________________________________________________________________
Mail to Name (if Different from You) _______________________________________________________________________________________________
__________________________________________________________________________________________________
Mailing Address
City _________________________________ State _____________ Zip _________________ Daytime Phone (_________) _________________________
I allow the following individual to receive the certificate(s) ______________________________________________________________________________
ADPH-HS-103 – 2/7/2020
IDENTIFICATION REQUIREMENTS FOR RESTRICTED ALABAMA VITAL RECORDS
Identification is required of any applicant requesting a restricted Alabama vital record (birth certificate
less than 125 years from the date of birth or death certificate less than 25 years from the date of death). The
applicant must submit a completed request and one form of identification from the Primary ID list below. In
the event the applicant is unable to provide identification from the Primary ID list, he/she may provide two
different forms of identification from the Secondary ID list.
If the applicant designates another individual to pick up a restricted certificate on his/her behalf, both
the applicant and the designee must provide acceptable identification.
The completed request, as well as a copy of all identification submitted, will be maintained by the vital
records office which processes the request.
Primary IDs Including PHOTO
Secondary IDs
(need at least one, current, expired no more
(need at least two)
than 60 days)
Alabama Driver’s License
-
Out-of-State Driver’s License
-
-
Expired, Government-Issued ID
-
-
Utility Bill (No more than 6 months old)
State-Issued Non-Driver ID
-
-
Work ID (If applicant is making personal
U.S. or Foreign Passport
-
request)
U.S. Certificate of Naturalization
-
-
Vehicle Registration or Vehicle Title
Certificate of Citizenship
-
-
Property Tax Bill
U.S. Military ID
-
-
Military Discharge (DD Form 214)
Work ID (If applicant is employee of
-
agency/company making request)
Voter Registration Card
-
-
Alien Resident Card (Temporary or
Health Insurance Card
-
Permanent)
Social Security Correspondence (not
-
Card)
U.S. Employment Authorization Card
-
-
Citizenship ID Card
U.S. Selective Service Card
-
-
Tribal ID
Recent DMV Receipt for Fines Paid
Pilot’s License
-
-
Fishing or Hunting License
-
-
Boating License
Copy of Police Report or other official
-
Concealed Weapons License
documents which support theft, in cases
where individual’s ID has been stolen
-
Ex-Felon ID
-
-
Inmate ID issued by the U.S. Dept of
Autism Spectrum Card
-
Justice w/ following documentation:
Immunization (Shot) Record
o Supporting documents from
*In special cases where applicant is unable to
institution if inmate is still in
provide any of these documents, please contact
custody, letter of release from
CHS at 334.206.5418.
institution if inmate has been
released
-
School ID (Must include current school
term)
-
Alabama Voter Identification Card
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