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)