Fillable Printable Application for a Certified Copy of a Birth Record - Michigan
Fillable Printable Application for a Certified Copy of a Birth Record - Michigan
Application for a Certified Copy of a Birth Record - Michigan
PART 6: FEES - Includes one certified copy or no-find letter
PART 5: INFORMATION NEEDED TO FIND BIRTH RECORD BEING REQUESTED
If the applicant’s current name is different than the way their birth name appears on the record, provide info below (required):
□ Marriage: Place of Marriage (state) ______________________________ Date of Marriage ____________________________
□ Court Ordered New Legal Name (court order must be provided): First ___________ Middle ____________ Last __________________
Date of Birth (mm, dd, year) Sex Place of Birth (hospital, city, county)
□ Male □ Female
Please include first, middle, and last names below: Is the person named on the record adopted? □ Yes □ No
Child’s Full Name Child’s Full Name
at Birth: _____________________________________ After Adoption: __________________________________
Mother’s Birth Name: ___________________________________ Adopted Mother’s Birth Name: ________________________
Father’s Birth Name: ___________________________________ Adopted Father’s Name:__________________________________
APPLICATION FOR A CERTIFIED COPY MICHIGAN BIRTH RECORD
PART 1: APPLICANT’S INFORMATION
PART 4: ELIGIBILITY - Select the category that qualifies YOU to request and receive the requested Michigan birth record per MCL 333.2882
For Accounting Use Only
Base Fee: Includes One Year Search
Age 64 and Under $34.00 $
Or Senior Citizen (Age 65+) Reduced Fee $14.00 $
(Must Be Requesting Own Birth Record)
Additional Certified Copies (Each) ____ x $16.00 $
Additional Years Search - Number of years ____ x $12.00 $
(when exact year unknown)
Indicate years you want searched: ______ ______ ______
EXPEDITED “RUSH” SERVICE (Additional) $12.00 $
PAYMENT TO “STATE OF MICHIGAN” TOTAL:
Applicant’s State Driver’s License
Name:_______________________________________________________ or Identification # _________________________
Mailing Address: ______________________________________ City: ____________________ State: _____ Zip: _________
(Cannot Send to General Delivery)
Daytime Phone - Required: ( ) _________________________ Other Phone: ( ) ______________________________
CURRENT VALID GOVERNMENT ISSUED PHOTO ID REQUIRED (See Back for Alternative Documents)
□ Person named on the record □ Heir of the deceased person named on the record, and
□ Parent named on the record • Relationship to decedent: ________________________
Note: If adopted, only adoptive parents are eligible • Decedent’s name at time of death: _________________
□ Legal guardian of the person named on the record • State where death occurred: ______________________
(Copy of court documented guardianship papers required) • Date of death (Year): ____________________________
□ Legally licensed attorney of subject of the record If not a Michigan death, must provide death certificate
(Letter on official letterhead required: Must provide state bar □ Court of competent jurisdiction (Court order & fee required)
number and the name of the person you represent) □ Birth record is at least 100 years old (no photo ID required)
PART 2: CERTIFICATION OF INFORMATION PROVIDED
By signing this application, I understand that I am agreeing to pay for a search of the State of Michigan Vital Records. This does not guarantee that a record
will be found.
Statement of Entitlement: Misstating an identity or assuming the identity of another person is subject to criminal penalties, e.g., Michigan Compiled Laws
333.2894(b) and 333.2898 and federal laws relating to falsification in obtaining a birth record. By signing this application, I state that I am eligible to receive this
birth record as indicated in the Eligibility Section of this application.
► Applicant’s Signature: _________________________________ Date: __________
IDENTITY THEFT PROTECTION ACT 445.65(1) and 445.69(1) prohibits anyone from obtaining a vital record by misrepresenting a person’s identity or attempting to use another
person’s identifying information. A person who violates this law is guilty of a felony punishable by imprisonment for up to 5 years or a fine of up to $25,000 or both.
Is your request complete? Don’t forget your ID!
PART 3: PURPOSE FOR REQUESTING THE RECORD
HAVE YOU DOUBLE CHECKED ??
PART 1: Print your name and mailing address
Cannot send to general delivery addresses
Include a telephone number to reach you
Enclose proper ID
PART 2: Sign your name
Do not print. Signature required.
PART 3:
Fill out purpose for requesting the record
PART 4: Indicate your eligibility
Provide all necessary documentation
PART 5: Complete all items
“Unknown” if information unavailable
“N/A” if not applicable
PART 6: Fees
Please total all fees correctly
PAYMENT
Check or money order made payable to the “State of
Michigan”
PROCESSING TIMES FOR MAIL REQUESTS
REGULAR SEARCH – The processing time for a regular request will
be approximately 5 weeks, depending on the volume of requests re-
ceived in our office.
EXPEDITED (RUSH) SEARCH – The processing time for a “rush”
request will be approximately 2 weeks, depending on the volume of
requests received in our office.
ADDITIONAL INFORMATION - If you find that the processing times
listed do not meet your needs, please call our Eligibility Unit at 517-
335-8666 and speak with a customer service representative. They
may be able to offer additional help to meet your individual situation.
IDENTIFICATION REQUIREMENTS
FOR APPLYING IN PERSON OR BY MAIL
FOR A MICHIGAN BIRTH RECORD
* Please Send Copies - Not Original Documents *
Under Michigan law, birth records are restricted documents. To re-
quest a birth record, a current valid, government issued identification
is required in order to establish eligibility (except for an unrestricted
birth record that is at least 100 years old). To protect you and the
community from identity theft, we require a copy of the applicant’s
government issued identification to be presented along with the appli-
cation and fees. Individuals under the age of 15 cannot request a
copy of their own birth record.
At least one of the following ID’s is required:
Current driver’s license with photo if unexpired, or expired less
than one year
Current state issued photo identification card unexpired, or
expired less than one year
Unexpired U.S. or foreign passport
U.S. military photo identification or military dependent photo
identification with current expiration date
Employment identification with photo, accompanied by a cur-
rent pay stub or W-2 form
Department of Corrections photo identification card, accompa-
nied by probation or discharge papers dated within last year
If a currently incarcerated prisoner, a Department of Correc-
tions photo identification card, accompanied by a verification of
incarceration by the facility on letterhead
For persons age 15 or older, current student photo ID with
either a current report card or current transcript
ALTERNATIVE DOCUMENTS can be submitted to be reviewed by
a supervisor if a current, valid government issued ID is not avail-
able. If you do not have one of the above, you will need to sub-
mit at least three of the following, and one MUST be dated within
the last year. Please note we cannot use a Social Security Card
or junk mail.
Examples might be: expired state or federal photo ID, marriage or
divorce certificate, child’s birth record, W-2, paycheck stub, bank
statement, voter or car registration, health insurance/Medicaid card,
state benefit card, utility bill, doctor/dentist/hospital bill, baptismal cer-
tificate, letter from a government agency such as Social Security or
the IRS, benefit statement from Social Security, school records, tax
records, incarceration records or land/rental agreement.
If you are still unable to provide any of the above-mentioned forms of
identification, please contact the Michigan Vital Records Office at 517-
335-8666 and speak with a customer service representative.
APPLYING IN PERSON
LOCATION:
Capitol View Building, 3rd Floor
201 Townsend Street
Lansing MI 48913 (across from the State Capitol)
LOBBY HOURS: 8:00 am - 5:00 pm M-F except for recog-
nized state holidays.
DIRECTIONS: Visit our website at: www.michigan.gov/mdch
or call 517-335-8666.
SAME DAY SERVICE: Orders at our counter must be placed
by 3:00 pm in order to receive same-day service. Additional
“rush” fee of $12.00 is required for same-day service and you
must allow up to a 2 hour waiting period for the order to be
processed. Genealogy requests may take longer.
PAYMENT: A money order, credit card or cash can be used
at our front counter. A personal check can also be used if
NOT same-day service.
PAYMENT INFORMATION
SEARCH FEES ARE NON-REFUNDABLE: Fees are estab-
lished by state statute. A basic one year search fee includes
either one certified copy of the record or an official statement
that the record is not filed with the state. A basic statewide
search includes the files for the year specified as the birth
year.
REFUNDABLE FEES: Payment for additional copies will be
refunded if the search indicated that the record is not filed
with the state. A refund check would be mailed to you by the
Michigan Department of Treasury, usually within 3-6 weeks.
MAIL APPLICATION TO
REGULAR MAIL TO: RUSH MAIL TO:
Vital Records Requests Vital Records RUSH
PO Box 30721 PO Box 30721
Lansing MI 48909 Lansing MI 48909
www.michigan.gov/mdch 517-335-8666
DCH-0569-BX Rev 8-2014
By Authority of MCL 333.2882(1)(a)(b) and MCL 333.2891(1-4)(8)
