Form R-109 "Application for a Non-certified Record of Birth Prior to Adoption" - Massachusetts

What Is Form R-109?

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

Form Details:

  • Released on April 1, 2016;
  • The latest edition provided by the Massachusetts 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 R-109 by clicking the link below or browse more documents and templates provided by the Massachusetts Department of Public Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form R-109 "Application for a Non-certified Record of Birth Prior to Adoption" - Massachusetts

Download PDF

Fill PDF online

Rate (4.5 / 5) 20 votes
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
RVRS USE ONLY
Rec’d_____________
REGISTRY OF VITAL RECORDS AND STATISTICS
150 MT. VERNON STREET, 1st Floor
#_________________
DORCHESTER, MA 02125-3105
Cert #_____________
Completed_________
APPLICATION FOR A NON-CERTIFIED RECORD OF BIRTH PRIOR TO ADOPTION
Initials_____________
(Please print legibly.)
Please fill out and return this form to the address above. If you are requesting a record by mail, make your check or money order payable to the
Commonwealth of Massachusetts and include $32.00 for each copy requested. DO NOT SEND CASH THROUGH THE MAIL. Records requested
in-person at the Registry counter are $20.00 per copy. Checks, money orders, and cash are accepted at the counter. Credit/debit cards are not
accepted. See additional instructions on the reverse of this form.
SUBJECT OF THE RECORD (ADOPTEE)
Number
of Copies:
Full Name on Current Birth Record (name at adoption) (First, Middle, Last)
Date of Birth* (Month, Day, Year)
Full Name of Adoptive Mother/Parent (First, Middle, Last)
Maiden surname of Adoptive Mother
Full Name of Adoptive Father/Parent (First, Middle, Last)
City/Town of Birth
Name on Pre-Adoption Birth Record (name at birth), if known
PERSON MAKING REQUEST
Full Legal Name (Current Name) (First, Middle, Last)
Relationship to Adoptee
Self
Adoptive parent
Adult child of deceased adoptee
Legal guardian of child (under 18
years) of a deceased adoptee
Mailing Address
Telephone number(s)
(Street/PO Box/Apt. #)
(City/Town, State, Zip)
AFFIDAVIT OF APPLICANT (If you are applying by mail, you must sign and date this section in the presence of a notary.)
WARNING: Providing false information under this oath or affirmation is punishable by fine and imprisonment under M.G.L. c.268 §6.
I hereby swear or affirm under the penalties of perjury that the information on this application is true to the best of my knowledge and belief.
________________________________________________________ _______________________
Signature
Date
On this _______________ day of ___________________________, ____________ before me, the undersigned notary public, personally appeared
____________________________________________________________________ who proved to me through satisfactory evidence of identification,
which were __________________________________________________________, to be the person whose name is signed on this document and
who swore or affirmed to me that the contents of the document were truthful and accurate to the best of their knowledge and belief and that they signed
this form voluntarily for its stated purpose.
Notary Public _____________________________________________________
My Commission Expires: ____________________________________________
IDENTIFICATION AND SUPPLEMENTAL DOCUMENTATION (see additional information on the reverse of this form)
IDENTIFICATION If you are applying in-person you will need to show one of the following identification documents. If you are applying by mail, you
must enclose a clear, legible, photocopy of the identification document. Alternative identification documents require prior approval by RVRS.
Valid, non-expired, driver’s license
 Valid, non-expired, identification card
Valid, non-expired, passport
issued by a department of motor vehicles
DOCUMENTATION If you are applying in-person and additional documentation is required (see reverse of form), you must provide an original certified
copy for inspection. If you are applying by mail and additional documentation is required, you must send an original certified copy that will be returned
to you with completion of your order.
Proof of name change:
Proof of death:
Proof of relationship:
Certified copy of a marriage certificate
Certified copy of death certificate
Certified copy of your birth certificate
Certified copy of a legal change of name decree
Certified copy of legal guardianship
Other (specify):
*Records on file at the Registry of Vital Records and Statistics date back to 1926. Earlier records are housed at the State Archives.
Form R-109 (04/2016)
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
RVRS USE ONLY
Rec’d_____________
REGISTRY OF VITAL RECORDS AND STATISTICS
150 MT. VERNON STREET, 1st Floor
#_________________
DORCHESTER, MA 02125-3105
Cert #_____________
Completed_________
APPLICATION FOR A NON-CERTIFIED RECORD OF BIRTH PRIOR TO ADOPTION
Initials_____________
(Please print legibly.)
Please fill out and return this form to the address above. If you are requesting a record by mail, make your check or money order payable to the
Commonwealth of Massachusetts and include $32.00 for each copy requested. DO NOT SEND CASH THROUGH THE MAIL. Records requested
in-person at the Registry counter are $20.00 per copy. Checks, money orders, and cash are accepted at the counter. Credit/debit cards are not
accepted. See additional instructions on the reverse of this form.
SUBJECT OF THE RECORD (ADOPTEE)
Number
of Copies:
Full Name on Current Birth Record (name at adoption) (First, Middle, Last)
Date of Birth* (Month, Day, Year)
Full Name of Adoptive Mother/Parent (First, Middle, Last)
Maiden surname of Adoptive Mother
Full Name of Adoptive Father/Parent (First, Middle, Last)
City/Town of Birth
Name on Pre-Adoption Birth Record (name at birth), if known
PERSON MAKING REQUEST
Full Legal Name (Current Name) (First, Middle, Last)
Relationship to Adoptee
Self
Adoptive parent
Adult child of deceased adoptee
Legal guardian of child (under 18
years) of a deceased adoptee
Mailing Address
Telephone number(s)
(Street/PO Box/Apt. #)
(City/Town, State, Zip)
AFFIDAVIT OF APPLICANT (If you are applying by mail, you must sign and date this section in the presence of a notary.)
WARNING: Providing false information under this oath or affirmation is punishable by fine and imprisonment under M.G.L. c.268 §6.
I hereby swear or affirm under the penalties of perjury that the information on this application is true to the best of my knowledge and belief.
________________________________________________________ _______________________
Signature
Date
On this _______________ day of ___________________________, ____________ before me, the undersigned notary public, personally appeared
____________________________________________________________________ who proved to me through satisfactory evidence of identification,
which were __________________________________________________________, to be the person whose name is signed on this document and
who swore or affirmed to me that the contents of the document were truthful and accurate to the best of their knowledge and belief and that they signed
this form voluntarily for its stated purpose.
Notary Public _____________________________________________________
My Commission Expires: ____________________________________________
IDENTIFICATION AND SUPPLEMENTAL DOCUMENTATION (see additional information on the reverse of this form)
IDENTIFICATION If you are applying in-person you will need to show one of the following identification documents. If you are applying by mail, you
must enclose a clear, legible, photocopy of the identification document. Alternative identification documents require prior approval by RVRS.
Valid, non-expired, driver’s license
 Valid, non-expired, identification card
Valid, non-expired, passport
issued by a department of motor vehicles
DOCUMENTATION If you are applying in-person and additional documentation is required (see reverse of form), you must provide an original certified
copy for inspection. If you are applying by mail and additional documentation is required, you must send an original certified copy that will be returned
to you with completion of your order.
Proof of name change:
Proof of death:
Proof of relationship:
Certified copy of a marriage certificate
Certified copy of death certificate
Certified copy of your birth certificate
Certified copy of a legal change of name decree
Certified copy of legal guardianship
Other (specify):
*Records on file at the Registry of Vital Records and Statistics date back to 1926. Earlier records are housed at the State Archives.
Form R-109 (04/2016)
APPLICATION FOR RECORD OF BIRTH PRIOR TO ADOPTION
Application Instructions
Who May Apply?
Beginning December 5, 2007, certain individuals specified by state law may apply for a copy of an initial birth record established prior to an adoption
(without first obtaining a judicial court order):
Adoptees who were born in Massachusetts on or before July 14, 1974.
An adult child (18 years or older) of a deceased parent who was an adoptee born in Massachusetts on or before July 14, 1974.
The parent or guardian of a child (under 18 years of age) whose deceased parent was an adoptee born in Massachusetts on or before July 14,
1974.
Beginning January 1, 2008, the following additional individuals specified by state law may also apply:
The adoptive parent of a child (under 18 years of age) born in Massachusetts on or after January 1, 2008.
Beginning January 1, 2026, the following additional individuals specified by state law may also apply:
An adult adoptee (18 years or older) who was born in Massachusetts on or after January 1, 2008.
Submit your application by mail or in person
If you are applying by mail, you must include copies of all identification and documentation listed below, and your signature must be notarized. The fee
for applying by mail is $32.00. Please do not send cash by mail. Checks and money orders should be made payable to the “Commonwealth of
Massachusetts.” Credit and debit cards are not accepted. RVRS will also accept applications by walk-in customers. If you are applying in person, your
application will be reviewed for completeness, your identification and documentation will be checked, payment will be taken, and the application will be
processed in the order it was received. The fee for applying in person is $20.00.
What you will receive if, after processing of your application, RVRS locates your birth record prior to adoption
You will receive a copy of the birth record that was registered with RVRS prior to adoption that lists among other items, the legal parent or parents listed
on the record at the time of birth. In a very few cases, there may have been an amendment prior to the adoption, for which you will receive the initial
record and any relevant amendments (e.g., paternity establishment).
The copy will be made on security paper to deter potential fraudulent use, and will contain, the following statement mandated by state law: “The
contents of this birth record are being released under section 2B of chapter 46 of the Massachusetts General Laws or under a court order. This record
was amended by adoption. This is not a certified copy of a birth record.”
Refunds
If the application can not be processed for any reason, it will be returned to you with a refund.
If you do not sign for the record that is sent to you by certified mail, and the record is returned to RVRS, you will NOT be issued a refund, as the cost
has already been incurred.
Identification Requirements
1.
If you are applying for your OWN record:
A current government-issued photo ID. (For applications by mail, attach a photocopy of the ID):
Current, not expired, driver’s license, or
Current, not expired, other ID issued by your state’s department of motor vehicles, or
Current, not expired, passport
If you cannot provide one of the identification items listed above, please call RVRS to be certain the ID you plan to provide is adequate.
Documentation of a change of name. If the name on your ID is different from your name at the time of your adoption, you must provide documentation
that will prove you are the person listed on the birth record. (For applications by mail, attach an original certified copy of the requested documentation.
Your original documents will be returned to you with the completed order). For example:
If your ID shows a married name, provide a certified copy of your marriage certificate that shows your name as it appears on your current
(adoptive) birth certificate and your name after marriage as it appears on your ID.
If your ID reflects a legal change of name, provide a certified copy of your legal change of name decree that shows your name as it appears on
your current (adoptive) birth certificate and your legal name as decreed by a court and as appears on your ID.
2.
If you are applying for YOUR PARENT’S record:
You must provide the identification listed above in numbered section 1, AND also show or provide:
A certified copy of your parent’s death record. If you are applying by mail, attach an original certified copy of your parent’s death record.
A certified copy of your birth record that shows you are the decedent’s child. If you are applying by mail, attach an original certified copy of
your parent’s death record.
Documentation of any change of name not reflected on the death certificate. If your parent’s death certificate does not contain in some format
a reference to his or her name at the time of adoption (e.g, maiden name, or name at birth or adoption), then you will need to provide evidence
of the change of name as described above in numbered section 1.
3.
If you are applying for YOUR ADOPTED CHILD’S record (beginning January 1, 2008):
You must provide the identification listed above in numbered section 1.
For all requests submitted by mail, notarization is required:
For requests by mail only, sign and date your application in the presence of a notary who will certify that your signature is authentic.
Questions
Contact the Registry of Vital Records and Statistics at (617) 740-2600 or by email at vital.recordsrequest@state.ma.us.
Form R-109 (11/2007)
Page of 2