Form Dch-0855 - Application To Establish Delayed Registration Of Foreign Birth Page 2

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Signature(s)

This form should be signed by the adoptive parents with their current names. The adoptive parents should verify

information listed for the adoptive birth record.

Signature of Person Adopting

Signature of Husband or Wife (if married)

COURT CERTIFICATION

The Probate Court of

County, Michigan

I hereby certify that this court has acknowledged the birth facts of the foreign born child, and the identified information about the adoptive parents dated

Month

Day

Year

CASE NO.

Judge

Probate Register

SEAL

Payment – The fee for establishing a delayed registration of

OFFICE USE ONLY – DO NOT WRITE IN THIS AREA

foreign birth is $50.00 and includes one copy of the new record.

Additional copies of the new record are available for

each