Sample Birth Certificate Letter
[TODAY’S DATE]
[YOUR FULL NAME HERE]
[YOUR STREET ADDRESS]
[CITY], TX [ZIPCODE]
Texas Vital Statistics
Department of State Health Services
PO Box 12040
Austin, TX 78711-2040
Dear Texas Vital Statistics,
My name is [YOUR FULL NAME]. I was born on [YOUR BIRTHDAY, INCLUDING YEAR] in [CITY WHERE YOU WERE BORN]. On [DATE YOU WERE ADOPTED], I was adopted by [ADOPTIVE PARENTS’ FULL NAMES]. My mother’s maiden name was [YOUR MOTHER’S MAIDEN NAME]. When I was adopted, a new birth certificate was created for me. It listed my adoptive parents’ names rather than my birth parents’ names. On [DATE ADOPTION LEGALLY ENDED], my adoption was ["REVOKED" OR "ANNULLED""].
I am writing to you because I would like my birth certificate to have the names of my actual parents, rather than the names of my former adoptive parents with whom I no longer have a legal relationship. My birth parents’ names were [BIRTH PARENTS’ FULL NAMES AT THE TIME OF YOUR BIRTH]. My mother’s maiden name was [YOUR MOTHER’S MAIDEN NAME]. Please issue me a birth certificate that reflects this original (pre-adoption) information.
Enclosed, please find a certified copy of Judge [JUDGE’S NAME]’s order p["REVOKING" OR "ANNULLING"] the adoption. Please also find a ["CHECK" OR "MONEY ORDER"] for $47. This includes the $25 fee to file a new birth certificate for me and the $22 fee to send me a certified copy.
Thank you,
[YOUR FULL NAME HERE]
Enclosures (2)
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