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Within the framework of Massachusetts law, the R 109 form plays a pivotal role in providing individuals with access to non-certified birth records prior to adoption. Crafted by the Massachusetts Department of Public Health Registry of Vital Records and Statistics, it marks a significant step towards transparency and accessibility to vital records. Enacted to facilitate adoptees, adoptive parents, adult children of departed adoptees, and legal guardians in obtaining pre-adoption birth information without a court order, the form embodies a progressive step in vital record access policies. Applicants are required to furnish detailed personal information, under the threat of penalties for perjury, ensuring both the integrity of the application process and the privacy of the records involved. The form specifies the necessary documents and identifications proving the applicant's eligibility and relationship to the adoptee, alongside a clear structure of fees for the request whether submitted by mail or in person. This access comes as a beacon of hope for many, allowing for the unveiling of previously inaccessible information and fostering a deeper understanding of personal history while adhering to legal standards and privacy measures. The R 109 form, therefore, stands as a crucial document, weaving through the fabric of legal, personal, and social narratives within the state of Massachusetts.

Massachusetts R 109 Sample

MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH REGISTRY OF VITAL RECORDS AND STATISTICS 150 MT. VERNON STREET, 1st Floor

DORCHESTER, MA 02125-3105

APPLICATION FOR A NON-CERTIFIED RECORD OF BIRTH PRIOR TO ADOPTION

(Please print legibly.)

RVRS USE ONLY Rec’d_____________

#_________________

Cert #_____________

Completed_________

Initials_____________

Please fill out and return this form to the address above. If you are requesting a record by mail, make your check or money order payable to the Commonwealth of Massachusetts and include $32.00 for each copy requested. DO NOT SEND CASH THROUGH THE MAIL. Records requested in-person at the Registry counter are $20.00 per copy. Checks, money orders, and cash are accepted at the counter. Credit/debit cards are not accepted. See additional instructions on the reverse of this form.

SUBJECT OF THE RECORD (ADOPTEE)

Number

 

of Copies:

 

 

Full Name on Current Birth Record (name at adoption) (First, Middle, Last)

Date of Birth* (Month, Day, Year)

Full Name of Adoptive Mother/Parent (First, Middle, Last)

Maiden surname of Adoptive Mother

Full Name of Adoptive Father/Parent (First, Middle, Last)

City/Town of Birth

Name on Pre-Adoption Birth Record (name at birth), if known

PERSON MAKING REQUEST

Full Legal Name (Current Name) (First, Middle, Last)

Relationship to Adoptee

 

Self

Adoptive parent

 

Adult child of deceased adoptee

 

Legal guardian of child (under 18

 

years) of a deceased adoptee

Mailing Address

Telephone number(s)

(Street/PO Box/Apt. #)

 

 

(City/Town, State, Zip)

 

 

 

 

 

AFFIDAVIT OF APPLICANT (If you are applying by mail, you must sign and date this section in the presence of a notary.) WARNING: Providing false information under this oath or affirmation is punishable by fine and imprisonment under M.G.L. c.268 §6.

I hereby swear or affirm under the penalties of perjury that the information on this application is true to the best of my knowledge and belief.

________________________________________________________ _______________________

Signature

Date

On this _______________ day of ___________________________, ____________ before me, the undersigned notary public, personally appeared

____________________________________________________________________ who proved to me through satisfactory evidence of identification,

which were __________________________________________________________, to be the person whose name is signed on this document and

who swore or affirmed to me that the contents of the document were truthful and accurate to the best of their knowledge and belief and that they signed

this form voluntarily for its stated purpose.

Notary Public _____________________________________________________

 

My Commission Expires: ____________________________________________

IDENTIFICATION AND SUPPLEMENTAL DOCUMENTATION (see additional information on the reverse of this form)

IDENTIFICATION If you are applying in-person you will need to show one of the following identification documents. If you are applying by mail, you must enclose a clear, legible, photocopy of the identification document. Alternative identification documents require prior approval by RVRS.

Valid, non-expired, driver’s license

 Valid, non-expired, identification card

Valid, non-expired, passport

 

issued by a department of motor vehicles

 

DOCUMENTATION If you are applying in-person and additional documentation is required (see reverse of form), you must provide an original certified copy for inspection. If you are applying by mail and additional documentation is required, you must send an original certified copy that will be returned to you with completion of your order.

Proof of name change:

Proof of death:

Proof of relationship:

Certified copy of a marriage certificate

Certified copy of death certificate

Certified copy of your birth certificate

Certified copy of a legal change of name decree

 

Certified copy of legal guardianship

Other (specify):

 

 

*Records on file at the Registry of Vital Records and Statistics date back to 1926. Earlier records are housed at the State Archives.

Form R-109 (04/2016)

APPLICATION FOR RECORD OF BIRTH PRIOR TO ADOPTION

Application Instructions

Who May Apply?

Beginning December 5, 2007, certain individuals specified by state law may apply for a copy of an initial birth record established prior to an adoption (without first obtaining a judicial court order):

Adoptees who were born in Massachusetts on or before July 14, 1974.

An adult child (18 years or older) of a deceased parent who was an adoptee born in Massachusetts on or before July 14, 1974.

The parent or guardian of a child (under 18 years of age) whose deceased parent was an adoptee born in Massachusetts on or before July 14, 1974.

Beginning January 1, 2008, the following additional individuals specified by state law may also apply:

The adoptive parent of a child (under 18 years of age) born in Massachusetts on or after January 1, 2008.

Beginning January 1, 2026, the following additional individuals specified by state law may also apply:

An adult adoptee (18 years or older) who was born in Massachusetts on or after January 1, 2008. Submit your application by mail or in person

If you are applying by mail, you must include copies of all identification and documentation listed below, and your signature must be notarized. The fee for applying by mail is $32.00. Please do not send cash by mail. Checks and money orders should be made payable to the “Commonwealth of Massachusetts.” Credit and debit cards are not accepted. RVRS will also accept applications by walk-in customers. If you are applying in person, your application will be reviewed for completeness, your identification and documentation will be checked, payment will be taken, and the application will be processed in the order it was received. The fee for applying in person is $20.00.

What you will receive if, after processing of your application, RVRS locates your birth record prior to adoption

You will receive a copy of the birth record that was registered with RVRS prior to adoption that lists among other items, the legal parent or parents listed on the record at the time of birth. In a very few cases, there may have been an amendment prior to the adoption, for which you will receive the initial record and any relevant amendments (e.g., paternity establishment).

The copy will be made on security paper to deter potential fraudulent use, and will contain, the following statement mandated by state law: “The contents of this birth record are being released under section 2B of chapter 46 of the Massachusetts General Laws or under a court order. This record was amended by adoption. This is not a certified copy of a birth record.”

Refunds

If the application can not be processed for any reason, it will be returned to you with a refund.

If you do not sign for the record that is sent to you by certified mail, and the record is returned to RVRS, you will NOT be issued a refund, as the cost has already been incurred.

Identification Requirements

1.If you are applying for your OWN record:

A current government-issued photo ID. (For applications by mail, attach a photocopy of the ID):

Current, not expired, driver’s license, or

Current, not expired, other ID issued by your state’s department of motor vehicles, or

Current, not expired, passport

If you cannot provide one of the identification items listed above, please call RVRS to be certain the ID you plan to provide is adequate.

Documentation of a change of name. If the name on your ID is different from your name at the time of your adoption, you must provide documentation that will prove you are the person listed on the birth record. (For applications by mail, attach an original certified copy of the requested documentation. Your original documents will be returned to you with the completed order). For example:

If your ID shows a married name, provide a certified copy of your marriage certificate that shows your name as it appears on your current (adoptive) birth certificate and your name after marriage as it appears on your ID.

If your ID reflects a legal change of name, provide a certified copy of your legal change of name decree that shows your name as it appears on your current (adoptive) birth certificate and your legal name as decreed by a court and as appears on your ID.

2.If you are applying for YOUR PARENT’S record:

You must provide the identification listed above in numbered section 1, AND also show or provide:

A certified copy of your parent’s death record. If you are applying by mail, attach an original certified copy of your parent’s death record.

A certified copy of your birth record that shows you are the decedent’s child. If you are applying by mail, attach an original certified copy of your parent’s death record.

Documentation of any change of name not reflected on the death certificate. If your parent’s death certificate does not contain in some format a reference to his or her name at the time of adoption (e.g, maiden name, or name at birth or adoption), then you will need to provide evidence of the change of name as described above in numbered section 1.

3.If you are applying for YOUR ADOPTED CHILD’S record (beginning January 1, 2008):

You must provide the identification listed above in numbered section 1.

For all requests submitted by mail, notarization is required:

For requests by mail only, sign and date your application in the presence of a notary who will certify that your signature is authentic.

Questions

Contact the Registry of Vital Records and Statistics at (617) 740-2600 or by email at vital.recordsrequest@state.ma.us.

Form R-109 (11/2007)

Get Massachusetts R 109 File

Form Breakdown

Fact Detail
Form Purpose This form is used to apply for a non-certified copy of a birth record prior to an adoption.
Eligibility Adoptees, adult children of deceased adoptees, adoptive parents, or legal guardians can apply, subject to specific date-of-birth requirements.
Fees $32.00 for mailed requests and $20.00 for in-person requests at the Registry counter.
Governing Law The application process and access to pre-adoption birth records are governed by Chapter 46, Section 2B of the Massachusetts General Laws.

How to Write Massachusetts R 109

Filling out the Massachusetts R 109 form is an important step for anyone looking to obtain a non-certified copy of a birth record prior to adoption. This form is specifically designed to facilitate the request process, ensuring that you can access important historical information. Remember, completing this form accurately is crucial for a smooth processing of your request. The instructions below are intended to guide you through each step of the process, making sure that your application is both complete and clear.

  1. Start by printing your details legibly in the required fields. This ensures that all your information is clear and easy to read.
  2. Enter the number of copies you wish to request in the designated space.
  3. Fill out the "Subject of the Record" section with the full name on the current birth record, date of birth, and the full names of the adoptive mother and father, including the mother's maiden surname. Also, provide the city or town of birth and the name on the pre-adoption birth record if known.
  4. In the "Person Making Request" section, write your full legal name, relationship to the adoptee, your complete mailing address, and telephone number(s).
  5. If you are applying by mail, the "Affidavit of Applicant" section must be signed and dated in the presence of a notary. This is to affirm that the information provided is true to the best of your knowledge under penalties of perjury.
  6. Include the date and the notary public's details where indicated.
  7. Identify the required identification and supplementary documentation. If applying in person, you must show one of the valid, non-expired IDs listed. If applying by mail, enclose a clear, legible photocopy of it. Any additional demanded documents, like proof of name change or proof of relationship, must either be shown (in person) or a certified copy mailed.
  8. Review the form for completeness and accuracy. This ensures that your application will not face unnecessary delays.
  9. Mail your application along with the $32.00 fee per copy requested by check or money order payable to the "Commonwealth of Massachusetts." Remember, cash should not be sent through mail. Alternatively, submit your application in person at the Registry counter along with the $20.00 fee per copy requested. Note that at the counter, checks, money orders, and cash are accepted, but credit/debit cards are not.

After submitting your application, the processing time begins. The Registry of Vital Records and Statistics will search for the birth record that was established prior to the adoption. If located, you will receive a non-certified copy of this record, which includes the legal parent or parents listed at the time of birth. Any amendments made prior to the adoption will also be included. The document will be on security paper with a specific statement indicating that it was released under certain conditions and is not a certified copy of the birth record. If, for any reason, your application cannot be processed, a refund will be issued. It is important to follow these steps carefully to ensure your request is fulfilled smoothly and efficiently.

Discover More on Massachusetts R 109

Who is eligible to apply for a Massachusetts R 109 form for a non-certified record of birth prior to adoption?

The eligibility to apply for a non-certified record of birth prior to adoption in Massachusetts is specified by state law. Specifically, adoptees born in Massachusetts on or before July 14, 1974, can apply. Additionally, an adult child (18 years or older) of a deceased adoptee born in Massachusetts by this date, or the parent or guardian of a child (under 18 years) whose parent was an adoptee and has passed away, are also eligible. Starting January 1, 2008, adoptive parents of children born in Massachusetts on or after this date can apply. Finally, from January 1, 2026, adult adoptees (18 years or older) born in Massachusetts on or after this date can apply as well.

What is the process for applying for a birth record prior to adoption using form R 109?

To request a birth record prior to adoption, you can submit the R 109 form either by mail or in person. If applying by mail, it's essential to include photocopies of all required identification and documentation as listed on the form, and your signature must be notarized. The mail application fee is $32.00, payable to the “Commonwealth of Massachusetts” via check or money order. Applying in person involves a review for completeness, identity and documentation verification, payment of a $20.00 fee, and processing in the order received. Credit and debit cards are not accepted for either application method.

What will you receive after applying for a non-certified birth record prior to adoption?

After processing your application, if the Registry of Vital Records and Statistics (RVRS) locates your birth record prior to adoption, you will receive a copy of the birth record that was registered before the adoption took place. This document will list the legal parents at birth among other information. It's important to note that this copy will be printed on security paper to prevent potential fraudulent use and will include a state-law-mandated statement indicating that the record was amended by adoption and is not a certified copy of the birth record.

What if the application for a non-certified birth record prior to adoption cannot be processed?

If, for any reason, the Registry of Vital Records and Statistics cannot process your application, your application, along with a refund, will be returned to you. However, it's important to be aware that if you do not sign for the record sent to you by certified mail, causing the record to be returned to RVRS, you will not receive a refund as the cost of processing the request has already been incurred.

Common mistakes

Filling out the Massachusetts R 109 form, an Application for a Non-Certified Record of Birth Prior to Adoption, is a straightforward process, but common errors can lead to delays or rejection of the application. Below are seven mistakes to avoid:

  1. Not printing legibly: Given that this form requires manual completion, it's crucial to print clearly and legibly. Illegible handwriting can result in processing errors or delays.

  2. Incorrect payment amount: The form specifies different fees for mail requests ($32.00) and in-person requests ($20.00). Sending the wrong amount can hinder the processing of your application.

  3. Omitting the notary section when applying by mail: If submitting by mail, the affidavit of the applicant requires notarization. Skipping this step can invalidate the entire application.

  4. Forgetting to include identification: For mail applications, a photocopy of a valid, non-expired government-issued photo ID must be included. In-person applicants need to show the original ID.

  5. Sending original documents without copies: When applying by mail, never send original identification or other necessary documents without keeping copies for yourself. Originals may be required for in-person applications but will be checked and immediately returned.

  6. Incomplete information: Each section of the form has mandatory fields that are crucial for the processing of the application. Leaving sections incomplete can lead to processing delays.

  7. Incorrect relationship selection: The form requires you to specify your relationship to the adoptee. Selecting the wrong option can result in the request being denied due to unauthorized access based on the state laws.

Avoiding these common mistakes can expedite the processing of the Massachusetts R 109 form and ensure a smoother application process for obtaining a non-certified record of birth prior to adoption.

Documents used along the form

When applying for a non-certified record of birth prior to adoption in Massachusetts using the R 109 form, several other documents are often required or highly recommended to support your application. These documents are vital for verifying your identity, your relationship to the adoptee, or any changes in name that may have occurred over time. Understanding these documents will ensure a smoother process in your application.

  • Valid, Non-Expired Government-Issued Photo ID: This is crucial for confirming the applicant's identity. Accepted forms include a driver's license, state identification card, or a passport. If the application is by mail, a clear, legible photocopy of the identification must be enclosed.
  • Certified Copy of a Marriage Certificate: Necessary when the applicant needs to prove a name change due to marriage. This is especially relevant if the name on the applicant's current ID differs from the name on the adoptee's birth record due to marriage.
  • Certified Copy of a Legal Change of Name Decree: Required if the applicant has legally changed their name for reasons other than marriage. This document must show the applicant's name both before and after the name change.
  • Certified Copy of Death Certificate: Needed if the applicant is the adult child or legal guardian of a deceased adoptee. It establishes the applicant's relationship to the adoptee and is essential for applications concerning the adoptee's pre-adoption birth record.
  • Certified Copy of Birth Certificate: Used to verify the applicant's relationship to the adoptee, particularly in cases where the adoptee is deceased, and the applicant is an immediate family member applying for the record.

Successfully gathering and submitting the appropriate documents along with the Massachusetts R 109 form is a key step in accessing a non-certified record of birth prior to adoption. Each document plays a unique role in establishing the identity and eligibility of the applicant, ensuring that sensitive information is released to the right individuals. Familiarizing yourself with these documents and their purposes can significantly streamline the application process, helping applicants to obtain the records they need in a timely and efficient manner.

Similar forms

The Massachusetts R 109 form is similar to other legal documents that are used for requesting vital records, albeit with specific variations tailored to its purpose. This document primarily serves individuals seeking non-certified copies of birth records before adoption, setting it apart with its particular focus. However, similarities in structure, purpose, and required information can be observed when compared to other forms within the context of obtaining vital records. Below are two examples of documents to which the R 109 form bears resemblance.

The Standard Birth Certificate Request Form

The Massachusetts R 109 form shows considerable similarity to the general request form for a birth certificate in terms of its function and the basic information it collects from applicants. Both forms typically require the requester's information, such as full legal name and relationship to the subject of the record, alongside details about the person whose birth certificate is being requested, including full name, date of birth, and place of birth. The primary difference lies in the specificity of the R 109 form – it is specifically designed for obtaining records prior to adoption. On the other hand, the standard birth certificate request form is broader, catering to all individuals seeking their birth records for various purposes, such as legal identification or passport application, without the specific context of adoption.

The Application for a Death Certificate

Similarly, the structure and content of the Massachusetts R 109 form have notable parallels with the form used to request a death certificate. Both forms necessitate detailed personal information about the applicant, including the relationship to the subject of the record, indicative of the legal rights or need to obtain such documents. They also require specifics about the individual whose certificate is being requested, though, naturally, the details pertain to different life events. The R 109 form is tailored towards accessing birth records before adoption, focusing on pre-adoption details and biological parental information, whereas the death certificate application focuses on information relevant to an individual's death, such as date and place of death. The purpose behind both forms is rooted in providing access to vital records for eligible parties, emphasizing the importance of accuracy and legality in the request process.

Dos and Don'ts

Completing the Massachusetts R 109 form, an application for a non-certified record of birth prior to adoption, requires attention to detail and accuracy. It is vital to follow the guidelines to ensure the smooth processing of your request. Below are essential dos and don'ts to consider:

  • Do print legibly when filling out the form to prevent any delays caused by illegible handwriting.
  • Do ensure all the information provided is accurate and truthful, as providing false information is punishable by fine and imprisonment.
  • Do make your check or money order payable to the Commonwealth of Massachusetts when requesting a record by mail.
  • Do include a clear, legible photocopy of your identification if you’re applying by mail. Acceptable forms of ID include a valid, non-expired driver’s license, state ID, or passport.
  • Do ensure your application signature is notarized if applying by mail, as this is a requirement for processing.
  • Do not send cash through the mail when paying for your requested copies to avoid the risk of loss.
  • Do not forget to include all required supplemental documentation, such as proof of relationship or name change, if applicable.
  • Do not overlook the application instructions on the reverse of the form, which provide additional crucial information.
  • Do not hesitate to contact the Registry of Vital Records and Statistics for any questions or clarifications. This can prevent unnecessary errors in your application process.

By adhering to these guidelines, you can streamline the process of obtaining a non-certified birth record prior to adoption from the Massachusetts Department of Public Health Registry of Vital Records and Statistics.

Misconceptions

When discussing the Massachusetts R 109 form, several misconceptions often arise. Clarifying these misunderstandings is crucial for individuals seeking records of birth prior to adoption.

  • First Misconception: The form is for obtaining a certified copy of a birth certificate.

    Actually, the R 109 form is specifically for requesting a non-certified record of birth prior to adoption. This distinction is important because the document provided is not a certified birth certificate, which has different legal uses.

  • Second Misconception: Everyone can request a record with this form.

    In reality, the eligibility to apply for a record using the R 109 form is restricted. According to state law, only adoptees born in Massachusetts before a specified date, adult children of deceased adoptees, and specific guardians or parents are eligible.

  • Third Misconception: You can pay with a credit or debit card.

    The instructions clearly state that credit and debit cards are not accepted. Payment must be made via check or money order by mail, or by check, money order, or cash in person.

  • Fourth Misconception: Applications can be completed online.

    As of now, the form must be submitted either by mail or in person. There is no provision for online submission of the R 109 form.

  • Fifth Misconception: The process is the same for in-person and mail applications.

    While both methods require identification and, if necessary, supplemental documentation, the fee differs, and in-person applications require immediate review and payment at the time of submission.

  • Sixth Misconception: Anyone can request a record for any adoptee.

    Only individuals with a specific relationship to the adoptee, such as being the adoptee themselves, an adoptive parent, or a legal guardian of a deceased adoptee's child, are authorized to make a request.

  • Seventh Misconception: All adoptees’ records are available.

    Access to records is determined by the date of birth of the adoptee, with different rules applying to those born before July 14, 1974, those born after January 1, 2008, and a forthcoming change in 2026 that will expand eligibility.

  • Eighth Misconception: The form is only for adoptees.

    While it primarily serves adoptees seeking their pre-adoption birth records, it also catizes to the needs of family members under specific conditions, such as when the adoptee is deceased.

  • Ninth Misconception: A notary is not necessary.

    If submitting by mail, the affidavit section of the application must be signed in the presence of a notary, underscoring the seriousness and formality of the information being attested to.

Understanding the specific requirements and restrictions of the Massachusetts R 109 form is crucial for a smooth request process. This avoids confusion and ensures that individuals provide the necessary information and documentation for their needs.

Key takeaways

The Massachusetts R 109 form is designed for individuals seeking a non-certified record of birth prior to an adoption. This document provides a structured process for requesting access to these special birth records. Below are some key takeaways regarding how to fill out and use this form effectively.

  • The form is applicable to adoptees born in Massachusetts, as well as to their immediate family members under certain conditions, with eligibility varying by the adoptee's birth date.
  • To apply, one must provide detailed personal information for both the adoptee and the person making the request, including names, dates of birth, and mailing addresses.
  • Affirmation of the truthfulness of the provided information through an affidavit is mandatory. If applying by mail, this affidavit must be notarized to validate the requester's signature.
  • A fee is required with submission: $32.00 for mail requests and $20.00 for in-person requests at the Registry counter. Acceptable payment methods vary depending on how the application is submitted.
  • Identification and, if applicable, additional documentation such as proof of death, proof of relationship, or proof of name change must be provided with the application.
  • If the requested birth record prior to adoption is found, the requester will receive a copy on security paper, indicating that the record was amended by adoption and is not certified.

This form serves as a critical tool for individuals seeking to obtain their birth records before adoption, providing a legal pathway to access such personal history.

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