Publications

 Practical operation documents
TitleAnnex C to the Special Commission Report of October 1994
Year of publication1994
PublisherHague Conference on Private International Law
Description
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RECOMMENDED MODEL FORM

CERTIFICATE OF CONFORMITY OF INTERCOUNTRY ADOPTION

Article 23 of the Hague Convention of 29 May 1993
on Protection of Children and Co-operation in Respect of Intercountry Adoption

 

1 -The undersigned authority:

-The undersigned authority:

 

(Name and address of the competent authority of the State of adoption)

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2 -Hereby certifies that the child:

-Hereby certifies that the child:

 

Family name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex: Male [ ] Female [ ]

Date of birth: day . . . . month . . . . year . . . .

Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Habitual residence: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 

3 -Was adopted according to the decision of the following authority:

-Was adopted according to the decision of the following authority:

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Date of the decision: . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date at which the decision became final: . . . . . . . . . . . . . . . . . . .

 

(If the adoption was made otherwise than by a decision of an authority, please specify the equivalent details)

 

4 -By the following person(s):

-By the following person(s):

 

a Family name of the adoptive father: . . . . . . . . . . . . . . . . . . . .

Family name of the adoptive father: . . . . . . . . . . . . . . . . . . . .

First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of birth: day . . . . month . . . . year . . . .

Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Habitual residence at the time of the adoption: . . . . . . . . . . . . . .

 

b Family name of the adoptive mother: . . . . . . . . . . . . . . . . . . . .

Family name of the adoptive mother: . . . . . . . . . . . . . . . . . . . .

First name(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of birth: day . . . . month . . . . year . . . .

Place of birth: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Habitual residence at the time of the adoption: . . . . . . . . . . . . . .

 

5 -The undersigned authority certifies that the adoption was made in accordance with the Convention and that the agreements under Article 17, sub-paragraph c, were given by:

-The undersigned authority certifies that the adoption was made in accordance with the Convention and that the agreements under Article 17, sub-paragraph c, were given by:

a Name and address of the Central Authority of the State of origin:

Name and address of the Central Authority of the State of origin:

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Date of the agreement: . . . . . . . . . . . . . . . . . . . . . . . . .

 

b Name and address of the Central Authority1 of the receiving State:

Name and address of the Central Authority1 of the receiving State:

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Date of the agreement: . . . . . . . . . . . . . . . . . . . . . . . . .

 

6 -[ ]The adoption had the effect of terminating the pre-existing legal parent-child relationship.

-[ ]The adoption had the effect of terminating the pre-existing legal parent-child relationship.

[ ]The adoption did not have the effect of terminating the pre-existing legal parent-child relationship.

 

 

Done at . . . . . . . . . . . , on . . . . . . . . . .

 

Signature / Seal

 

(1)Or the public authority, body or person designated in accordance with Article 22(1) or (2) of the Convention.