New Jersey Department of Health

Vital Statistics and Registry

P.O. Box 370, Trenton, NJ 08625-0370	APPLICATION FOR AN UNCERTIFIED COPY OF

AN ADOPTED PERSON’S ORIGINAL BIRTH RECORD
Amendments to the Vital Statistics Law offer opportunities for adult adopted persons to obtain uncertified copies of their original birth certificates effective January 1, 2017.

A qualified applicant will receive an uncertified copy of the adoptee’s Original Birth Certificate, which will be clearly marked that it is for informational purposes only. The uncertified copy cannot be used for legal proof of identity, citizenship or as a substitute for an Official Birth Certificate. Under the new law, a birth parent is permitted to redact his or her personal identifying information from his or her biological child’s original birth certificate if the adoption was finalized before August 1, 2015, and the birth parent makes the redaction request on or before December 31, 2016. Therefore, a copy of the adopted person’s original birth certificate may have birth parent information redacted from it. The applicant may also receive family history information and birth parent contact information, if this information was supplied by the birth parents. Birth parents have the option of no contact, direct contact or contact through an intermediary.

Please fill out and return this application by mail to the address above. The fee for uncertified copies is $25 for the first copy and $2 for each additional copy ordered at the same time. Please make your check or money order payable to “Treasurer, State of New Jersey.”

We need the following information in order to find and match your request with our existing files. If you fail to provide complete and accurate information, then we may be unable to accept and process your request. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.

INFORMATION ON PERSON (APPLICANT) MAKING REQUEST
Full Legal (Current) Name of Applicant (First, Middle, Last)

Relationship to Person Named on Birth Record

Adopted person (self)

Direct descendant, sibling or spouse of the adopted person

Adoptive parent, legal guardian or other legal representative of the adopted person

Agency of the State or Federal government for official purposes
Current Mailing Address (Street/PO Box/Apt. #) (Must Match Address on ID)

City	State	Zip Code

Daytime Telephone Number

Applicant’s Signature

Date of Application

INFORMATION ON SUBJECT OF THE BIRTH RECORD (ADOPTED PERSON)

[From the adoptee’s current, post-adoption birth certificate (in case information was changed at time of adoption)]
REQUIRED INFORMATION
Full Name on Current Birth Record (Name at Adoption) (First, Middle, Last)

Number of Copies Requested

Place of Birth (City, Town)

Place of Birth (County)

Exact Date of Birth

Full Name of Adoptive Mother/Parent (First, Middle, Last)

Maiden Surname of Adoptive Mother

Full Name of Adoptive Father/Parent (First, Middle, Last)

ADDITIONAL INFORMATION, IF KNOWN, TO THE BEST OF THE APPLICANT’S KNOWLEDGE
Full Name on Original, Pre-Adoption Birth Record, if Known (First, Middle, Last)

Date of Birth on Original, if Known

(if different from above)

Full Name of Birth Mother/Parent, if Known (First, Middle, Last)

Maiden Surname of Birth Mother, if Known

Full Name of Birth Father/Parent, if Known (First, Middle, Last)

Application Check List: Have you enclosed and completed all required information?

All Items on Application	Payment	Acceptable Forms of ID	Proof of Relationship	Mailing Address Matches ID

FOR STATE USE ONLY
Payment Type:

( Cash ( M/O ( Check	Payment Amount:

$	ID Viewed:	Processed By
REG-41

MAY 16

REG-27, Application for Non-Genealogical Certification or Certified Copy of a Vital Record, Spanish and English

non-genealogical, non-genealogy, certified copy, reg-27, vital statistics, certification, application, spanish, english

EWhite

2016-01-20

NJSDH