Certificate of Adoption (BVS-160)


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       VS-160 REV 7/2007 
                  STATE OF TEXAS CERTIFICATE OF ADOPTION 
 
1. NAME OF CHILD (BEFORE ADOPTION)           FIRST                            MIDDLE                                            LAST 
 
2. DATE OF BIRTH (mm/dd/yyyy)  
  
3. SEX 
  
4. TIME OF BIRTH 
 
5. NAME OF HOSPITAL 
 
6. CITY 
 
7. COUNTY 
 
8. STATE OR FOREIGN 
COUNTRY 
 
SECTION 1 
 
ORIGINAL 
BIRTH 
INFORMATION 9. NATURAL  MOTHER      FIRST                     MIDDLE                       LAST (MAIDEN) 
 
10. NATURAL  FATHER                   FIRST                         MIDDLE                         LAST 
 
11. NEW NAME OF CHILD AFTER ADOPTION       FIRST                                                  MIDDLE                                                   LAST                                                           SUFFIX I 
 
12. IS THIS A SINGLE PARENT ADOPTION? 
 
          YES           NO 
13. DO YOU WANT A NEW BIRTH CERTIFICATE?   
 
    YES           NO 
14. NAME OF ADOPTIVE FATHER                         FIRST                                MIDDLE                   LAST                          SUFFIX 
 
15. DATE OF BIRTH (mm/dd/yyyy) 
 
16. BIRTHPLACE (STATE OR FOREIGN 
COUNTRY) 
 
17. RACE 
 
18a. HISPANIC ORIGIN?  
 
  YES   NO 
18b. IF YES, SPECIFY 
 
19. RELATIONSHIP:     STEP-PARENT 
 OTHER RELATIVE  NON-RELATIVE 
 NATURAL FATHER 
 
20. NAME OF ADOPTIVE  MOTHER                   FIRST                                   MIDDLE                                                            MAIDEN 
 
21. DATE OF BIRTH   (mm/dd/yyyy) 
22. BIRTHPLACE (STATE OR FOREIGN COUNTRY) 
 
23. RACE 
 
24a. HISPANIC ORIGIN?  
 
 YES   NO 
24b. IF YES, SPECIFY 
 
25. RELATIONSHIP:    STEP-PARENT 
OTHER RELATIVEL  NON-RELATIVE 
 NATURAL MOTHER 
26a. MAILING ADDRESS OF ADOPTIVE MOTHER AT TIME OF BIRTH - STREET #  AND NAME                CITY                COUNTY                STATE           ZIP 26b. INSIDE CITY LIMITS 
 
  YES   NO 
27. SIGNATURE OF EITHER ADOPTIVE PARENT 
 
28a. ADOPTIVE FATHER'S SSN 28b.  
 
28b. ADOPTIVE MOTHER'S SSN 
 
  
SECTION 2 
 
 
 
  
 
 
ADOPTION 
INFORMATION 
COMPLETE THIS 
SECTION 
AS IT SHOULD 
APPEAR ON 
THE "NEW" 
BIRTH 
RECORD 
29. ADOPTIVE PARENTS                                        STREET # AND NAME                     CITY                                                     STATE                          ZIP   
CURRENT  MAILING ADDRESS 
 
30. ADOPTIVE PARENTS TELEPHONE NO. 
 
31. NATURAL MOTHER                    FIRST                                                   MIDDLE                                            LAST (MAIDEN) 
 
32. SSN 
 
33. MAILING ADDRESS                                            STREET # AND NAME                                                   CITY                                                                                    STATE ZIP 
 
34. NATURAL FATHER              FIRST                                                                      MIDDLE                                                              LAST 
 
35. SSN 
 
36. MAILING ADDRESS                                              STREET # AND NAME                                            CITY                                                                           STATE                               ZIP 
 
37.GUARDIAN'S NAME                    FIRST                                                                 MIDDLE                                                                LAST 
 
38. SSN 
 
39. MAILING ADDRESS                                             STREET # AND NAME                                            CITY                                                                             STATE                         ZIP 
 
40. MANAGING CONSERVATOR'S NAME                 FIRST                                                      MIDDLE                                                 LAST 
 
41. SSN 
42. MAILING ADDRESS                                             STREET # AND NAME                                     CITY                                      STATE                                                               ZIP 
 
43.OTHER PERSON                                FIRST                                                       MIDDLE                                                                  LAST 
 
144. SSN 
 
 
SECTION 3 
 
 
 
 
 
NAME AND 
ADDRESS OF 
ANY PERSON 
WHOSE 
CONSENT WAS 
REQUIRED OR 
WAIVED UNDER 
CHAPTER 162, 
FAMILY CODE 
45. MAILING ADDRESS                                               STREET # AND NAME                                           CITY                                            STATE                                            ZIP 
 
46.  NAME OF ATTORNEY OF RECORD 
 
 ATTORNEY 
47. MAILING ADDRESS OF ATTORNEY 
 
48. TELEPHONE NUMBER 
 
49. NAME OF CHILD PLACING AGENCY (IF APPLICABLE) 
 
50. LICENSE NUMBER 
 
 
 
AGENCY 51. MAILING ADDRESS OF AGENCY (IF APPLICABLE) 
 
52. TELEPHONE NUMBER 
 
53. NAME OF ADOPTION REGISTRY 
 
REGISTRY 
54. MAILING ADDRESS OF REGISTRY 
 
 55. TELEPHONE NUMBER 
 
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SECTION 4 
 
CERTIFICATION 
OF COURT 
56. I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AS STATED IN DECREE WHICH WAS GRANTED 
 
ON  _________________________ DAY OF      ________________________________, _________________ 
 
IN THE  _________________________________  COURT OF ______________________________________ COUNTY, TEXAS  IN CAUSE # ___________________________ 
 
  
 
                                  ____________________________________________________ 
                                                      DISTRICT CLERK'S SIGNATURE 
BUDGET ZZ 708-153 
       VS-160 REV 7/2007 
       
 
These instructions are designed to assist you in the proper completion of the Certificate of Adoption. Should you have 
any questions, please contact our office at (512)458-7111 for assistance.  PLEASE TYPE OR PRINT LEGIBLY. 
 
SECTION 1 
The information in this section relates to the child’s information at birth. Enter the name of the child prior to adoption in 
item 1. This information must be supplied to enable us to locate the adoptee’s original certificate of birth. 
 
SECTION 2 
Item 11 must show the full name of the child as it should be after adoption. Items 12-30 relate to personal information of 
the adoptive parents. The responses in these items should be the information as of the date of the adoptees birth  
(item 2). This information will be transferred to the NEW certificate of birth for the adopted child. 
 
If this is a step-parent adoption, the information concerning the natural parent MUST also be furnished. 
 
If a NEW certificate is to be prepared, mark “YES” in item 13.  
 
The signature of either the adoptive mother or adoptive father must appear in item 27 verifying the information in 
Section 2. 
 
SECTION 3  
Complete items 31 through 45 for any person whose consent was required or waived under Chapter 162, Texas Family 
Code. This information is required for inclusion in the Central Adoption Registry. All applicable blocks must be 
completed. If any or all of the information in items 37 through 45 are not applicable, leave the item(s) blank. 
 
If more than one father is identified and consents to the adoption, list the additional “father” information in an alternate 
section. Use the “Guardian’s Name” or “Other Person” fields if not needed otherwise. Mark through the printed title in 
the item, write “father”, and complete the blanks as required. 
 
Enter the name, mailing address and telephone number of the attorney of record in items 46-48. 
 
Enter the information relating to the child placing agency in items 49-52, if applicable. 
 
In items 53-55 enter the information relating to the adoption registry maintaining the information on this adoption,  
if applicable. 
 
SECTION 4 
This section MUST be completed by the clerk of the court granting the adoption. If Section 4 is not completed by the 
clerk of the court granting the adoption, a CERTIFIED COPY of the final decree of adoption MUST be attached to the 
certificate of adoption form. 
 
MAIL THE PROPERLY COMPLETED CERTIFICATE OF ADOPTION WITH THE  
**APPROPRIATE FEES TO: 
 
TEXAS VITAL STATISTICS 
DEPARTMENT OF STATE HEALTH SERVICES 
PO BOX 12040 
AUSTIN TX 78711-2040 
 
**EXPLANATION OF FEES: 
 
The Texas Vital Statistics Unit is now collecting the CAR funds (Central Adoption Registry), as required by Chapter 
§108.006(b) of the Family Code. These fees are to be submitted along with the additional filing fees and certified copy 
fees collected by the Unit. 
 
A $15.00 CAR (Central Adoption Registry) FUND FEE IS REQUIRED ON EACH ADOPTION DECREE GRANTED IN 
TEXAS. 
 
IF THE CHILD WAS BORN IN TEXAS OR A FOREIGN COUNTRY AND A NEW BIRTH CERTIFICATE BASED UPON 
ADOPTION MUST BE FILED, A FEE OF $25.00 IS REQUIRED. 
 
TO RECEIVE ONE CERTIFIED COPY OF THE NEW BIRTH RECORD, PLEASE INCLUDE AN ADDITONAL FEE OF 
$22.00. 
 
THE TOTAL FEE OF $62.00 MAY BE SUBMITTED WITH ONE CHECK, PAYABLE TO TEXAS VITAL STATISTICS. 
 
IF THE CHILD WAS BORN IN ANOTHER STATE AND THE ADOPTION WAS GRANTED IN TEXAS, ONLY THE 
$15.00 CAR FUND IS REQUIRED.