Birth Certificate Request

       NON-REFUNDABLE SEARCH FEE
                                                Proof of identity of applicant:                      STATE PERSONNEL USE ONLY ________
                  Birth Certificate             Applicant must provide one of these:
Name on birth record:                               ❒   Driver’s License
                                                                                                     CERT# _______________ # of copies_____
                                                    ❒   Passport

Date of Birth:                                      ❒   Government issued picture I.D.               AMOUNT PAID
                                                OR two of these:
Place of Birth:
                                                    ❒   Utility bills                                CASH ______ CHECK#______ CC_______
Parents Names (with parent/mother’s maiden):
                                                    ❒   Bank statements
                                                    ❒   Vehicle registration
                                                                                                     ID Shown:
                                                    ❒   Income tax return
Applicant Name:                                     ❒   Personal Check w/ address
                                                                                                     ID #:
                                                    ❒   A previously issued vital record
Applicant Address:                                  ❒   Letter from government agency requesting
                                                        record (DHHS, WIC)                           Expires:
                                                    ❒   Department of Corrections I.D. card
                                                    ❒   Social Security Card                         Notes:
Indicate your Relationship to the person on
                                                    ❒   DD 214
requested record below:
                                                    ❒   Hospital; birth worksheet
              ❒ Self
                                                    ❒   License/rental agreement
              ❒ Spouse                              ❒   Pay stub
              ❒ Registered Domestic Partner         ❒   W-2
              ❒ Parent                              ❒   Voter Registration card
              ❒ Guardian                            ❒   Disability award from SSA

❒ Descendant ❒ Other _________________ Establishing eligibility to acquire record:

❒ Attorney of person on record

❒ Related applicants must provide proof of

❒ Genealogist ID # ____________ lineage. By signing below, I swear/affirm that the

❒ Domestic Partners must provide proof of information above is true and correct. registration of domestic partnership Applicant Signature: ❒ Attorneys must provide a signed, notarized release from family Today’s Date: ❒ Genealogists must provide a state-issued st card $15 for 1 copy, $6 for each additional copy NON-REFUNDABLE SEARCH FEE ❒ Do not retain copies of proof provided or incounterbthform.doc R 12/2013 note any specific numbers