Missouri DHSS - Vital Records Applications and Forms · Missouri state form
580-3140 Birth Parent Contact Preference Form
Use Form 580-3140 to record your contact preference for an adoptee and provide information to help Vital Records identify the original birth certificate.
- What this form is
- A birth parent completes Form 580-3140 to state whether they prefer no contact, contact through an intermediary, or direct contact with the adoptee. The form also requests information to help the Bureau of Vital Records identify the original birth certificate. The birth parent’s signature must be notarized. The document states that a non-refundable $15 fee must accompany the form.
- Who needs it
- A birth parent who wants to record a contact preference and provide identifying information for the adoptee’s original birth certificate.
- Why it needs a notary
- The birth parent’s signature must be notarized in the notary section. You can complete this step online with a commissioned online notary.
- How to submit it
- Complete the form, include the non-refundable $15 fee by check or money order payable to the Missouri Department of Health and Senior Services, and mail it to the Bureau of Vital Records, P.O. Box 570, Jefferson City, MO 65102-0570.
Questions
Who completes the Birth Parent Contact Preference Form?
The form states that the signer attests to being the birth parent of the adoptee whose original birth certificate information is provided.
Does the Birth Parent Contact Preference Form need to be notarized?
Yes. The form includes a notary section for the birth parent’s signature, with a jurat stating “Subscribed and sworn before me.” A commissioned online notary can notarize it online.
How do I submit Form 580-3140?
Mail the completed form with a $15 check or money order payable to the Missouri Department of Health and Senior Services to the Bureau of Vital Records, P.O. Box 570, Jefferson City, MO 65102-0570.