Fillable Printable Application for a Copy of a Birth Certificate - North Carolina

Application for a Copy of a Birth Certificate - North Carolina

DHHS-VR-B (Revised 05/2015)

N.C. Vital Records (Review 05/2018)

North Carolina Department of Health and Human Services

Division of Public Health • N.C. Vital Records

http://vitalrecords.nc.gov

Telephone: 919-733-3000

Mail: 1903 Mail Service Center Location: 225 North McDowell St.

Raleigh, NC 27699-1903 Raleigh, NC 27603-1382

PLEASE PRINT

Application for a Copy of a North Carolina Birth Certiﬁ cate

Certiﬁ cate Information

Full Name on Certiﬁ cate

(If adopted, provide new information)

_________________________________________________________________

First Name Middle Name Last Name

Date of Birth ____ | ____ | ________

Month Day Year

Sex  Male  Female

Were parents married at time of

birth?  Yes  No

Is this person deceased?  Yes  No

Place of Birth _________________________________________

City County

Full Name of Parent

(Adoptive parent, if applies)

____________________________________________________________________

First Name Middle Name Last Name Last Name (before any marriage, if different)

Full Name of Parent

(Adoptive parent, if applies)

____________________________________________________________________

First Name Middle Name Last Name Last Name (before any marriage, if different)

Check all boxes that apply; add the fees in 1–3

and place the total amount in #4.

See further instructions on Page 2.

Your Relationship to the Person Whose Certiﬁ cate is Requested:

(Check one)

1. Order Certiﬁ cate

Processing times vary.

Check website for current information.

(Non-refundable fee)

 Certiﬁ cate Search and First Copy ($24) $_______

 #___ additional copies x $15 $_______

 Certiﬁ ed (Legally suitable for any purpose)

 Uncertiﬁ ed (Suitable for research purposes)

 Self

 Spouse (Current)

 Brother/Sister

 Child

 Parent/Step-Parent

 Authorized agent, attorney or legal representative

of the person listed (Proof REQUIRED)

 Other (may not be entitled to a certiﬁ ed copy)

(Please Print)

Requestor: ____________________________________________________________

Print Name of Person Requesting a Certiﬁ cate

Address: ____________________________________________________________

Street Address (P.O. Box cannot be used for expedited shipping)

_______________________________________________________________________

P.O. Box (If mailing to a P.O. Box, street address must also be listed above)

_______________________________________________________________________

City, State, Zip Code

_______________________________________________________________________

(Area Code) Telephone Number (During business hours)

Email Address: _________________________________________________________

Payment: Please pay with a cashier’s check or money order made payable to N.C. Vital

Records. Personal checks are not accepted. Requests that are submitted with no payment,

or incomplete payment or incomplete information will be returned. Credit card payment

is available for walk-in customers.

ID OF THE PERSON REQUESTING A CERTIFICATE IS REQUIRED:

See Page 2 for a list of acceptable IDs. Requests that do not include proper identiﬁ cation

will be returned.

2. Record Changes (Only if applies)

Appointment required for in-person services.

($15 non-refundable processing fee)

 Adoption $_______

 Amendment $_______

 Name Change $_______

 Legitimation Court Order $_______

 Legitimation (mother married father

after child’s birth) $_______

 Paternity (no fee) $ 00.00

 Other _____________________ $_______

3. Faster Service (Choose only one)

Optional for mail-in requests

($15 non-refundable expedite fee)

 Walk-in Service ($15) $_______

 Expedited Processing ($15) $_______

(Shipped by regular mail)

 Expedited Processing and

Expedited Shipping ($35) $_______

(Call for expedited shipping fees outside the continental United States)

4. Total Fees

(Add 1+2+3 above for total) $_______

I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of N.C. Law (G.S. 130A-26A)

to make a false statement on this application or to unlawfully obtain a copy or a certiﬁ ed copy of a birth certiﬁ cate.

___________________________________________________________ _________________________________________

Signature of Person Requesting a Certiﬁ cate Date

Ofﬁ ce Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame _________________________________

Amount received: $_______________________ Identiﬁ cation presented_________________________________________________________________________

Request number ___________________________________________ Request date _______________________________________________________________

 Grandparent

Specify

How do you plan to use this record?

DHHS-VR-B (Revised 05/2015)

N.C. Vital Records (Review 05/2018)

Order Certiﬁ cate

A certiﬁ cate search costs $24 and includes one copy if the certiﬁ cate is located. The search covers a three year

period. Requests are processed in the order received and can take up to ﬁ ve weeks plus the mail delivery time.

The search fee is required to process a request and is non-refundable even if a record cannot be located.

Record Changes

Complete this section only if you are making a request to change information on the birth certiﬁ cate. The $15

processing fee to review your request is non-refundable. In-person assistance for this service is by appointment

only. Please call (919) 792-5986 to schedule an appointment. If your request involves more than one birth

record, the $15 processing fee applies to each individual’s birth record that requires change(s).

Faster Service

To receive expedited service you MUST write “Expedite” on the outside of the envelope. Expedited requests

will be processed within 10 business days. This does not include the additional day(s) for shipping. This is a

non-refundable fee.

Identiﬁ cation Requirement

Due to identity theft and other fraudulent use of vital records, ID of the person requesting a certiﬁ cate is

REQUIRED. Requests that do not include ID will be returned. You MUST include a legible photocopy of

one of the photo IDs listed below with your request:

 Current state-issued driver’s license (address must match requestor’s address on application)

 Current state-issued non-driver photo ID card (address must match requestor’s address on application)

 Current Passport or Visa (must include photo)

 Current U.S. military ID

 Current Department of Corrections photo ID card dated within the last year

 Current state or U.S. government agency photo ID card (for persons requesting certiﬁ cates as part of that

agency’s business)

 Current student ID card with copy of transcript

If you do not have one of the IDs listed above, you must provide legible photocopies of TWO of the following

(must be two DIFFERENT forms of ID):

 Temporary driver’s license

 Current utility bill with current address

 Car registration or title with current address

 Bank statement with current address

 Pay stub with current address

 Income tax return/W-2 form showing current address

 Letter from government agency dated within the last six months and showing current address

 State-issued concealed weapon permit showing current address

If you are unable to meet our ID requirements, a family member or other person

who is entitled to obtain the certiﬁ cate, and who can meet the ID requirements, may request it.

A list of persons entitled to obtain certiﬁ cates is located on our website at

http://vitalrecords.nc.gov/faqs.htm.