FORM NO.1A ( Legal information) (See rule 5) FORM NO.

1A Statistical information (See rule 5)

BIRTH REPORT FOR ADOPTED CHILD BIRTH REPORT FOR ADOPTED CHILD
[SEE REVERSE FOR INSTRUCTIONS] [SEE REVERSE FOR INSTRUCTIONS]
This part to be added to the Birth Register This part to be detached and sent for statistical processing
To be filled by the informant To be filled by the informant
1*. Date of Birth : D D - M M - Y Y Y Y
14. For Religion [Enter appropriate religion
2*. Sex (Enter “Male” or “Female” or “Transgender person”) : “Hindu” or Muslim” or “Christian” or “Sikh” or
Child’s details (If name is changed on adoption, write new name):- “Buddhist” or “Jain” or “Other (Please specify)”]
3.
(a) Name of the Child First Name Middle Name Last Name
(b) Aadhaar No. (if available): (a) Religion of Adoptive Father:
4*. Mother’s Details (If known):-
(a) Name: First Name Middle Name Last Name (b) Religion of Adoptive Mother:
(b)
Aadhaar No. (if available):
(c) 15. Adoptive Father’s level of education:
Mobile No:
(d) Email Id:
5*. Father’s Details(If known):- Adoptive Mother’s level of education:
16.
(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available): Adoptive Father’s Occupation:

To be detached and sent for statistical processing

17.
(c)
Mobile No:
(d) Email Id:
18. Adoptive Mother’s Occupation:
6. Details of adoption deed / order:-
(a) Date: D D - M M - Y Y Y Y
(b) Number of Adoption deed / order:
7. Adoptive Mother’s Details:-
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c)
Mobile No:
(d) Email Id:
1

8. Adoptive Father’s Details:-

(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
Mobile No:
(d)
Email Id:
9. Address of adoptive parents as recorded in Adoption deed / order: House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
10. Permanent address of adoptive parents: House No: Locality:
Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
11*. Place of birth: (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the “Hospital /
Institution” or the address of the “House” or ‘Other place” where the birth took place) :
1.Hospital / Institution Name :
2. House 3. Other place Address : House No. Locality:
Ward number (in case of town and if available): Town or Village:
Sub-district: District:
State or Union Territory: PIN Code:
12. If adoption through agency write the address of the Adoption agency: House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
13. Informant’s Details:-
(a) Name: First Name Middle Name Last Name

(b) Aadhaar No.(if available):

(c) Mobile No:
Email Id:
(d)
Address : House No: Locality: Ward number (in case of town and if available):
(e)
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
*As contained in the original birth certificate.
DECLARATION: I have furnished true information to the best of my knowledge and belief. I am aware of the
penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting
false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other Subsidies,
benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar authentication.
(After completing all columns 1 to 18,
informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or (Columns to be filled are over. Now put signature at left)
left thumb mark of the informant

To be filled by the Registrar To be filled by the Registrar

Registration No. : Name Code No.
District
Registration Date: D D - M M - Y Y Y Y
Sub-District
Registration Unit : Town/Village :
Town / Village: Sub-District: Registration Unit : Registration No. :
District: Registration Date: D D - M M - Y Y Y Y
Remarks ( if any): Date of Birth : D D - M M - Y Y Y Y
Sex : Male / Female / Transgender person
Place of Birth: 1. Hospital/Institution 2. House 3.
Other place

Name and Signature of the Registrar Name and Signature of the Registrar