Birth Parent Request for Original Birth Certificate from Adoption Sealed File

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 R equest 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
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Birth Parent Request for Original Birth Certificate from Adoption Sealed File PDF

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