Fillable Printable Application for Certified Copy of Birth Record - Pennsylvania

Application for Certified Copy of Birth Record - Pennsylvania

HD1105F REV 08//07

BIRTH

Application for Certified Copy of Birth Record

Pennsylvania Department of Health Division of Vital Records

BIRTH

PART 1: By my signature below, I state I am the person whom I represent myself to be herein, and I affirm the information within

this form is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to

authorities. In addition, I acknowledge that misstating my identity or assuming the identity of another person may subject me to

misdemeanor or felony criminal penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania

Crimes Code. (Note: Signature must agree with name listed in Parts 2 and 5 of this form.)

Signature of person making request (Do not print): ___________________________________________________________________

Signature required on ALL requests. Must be 18 years of age or older to apply. If under 18, immediate family member must request record.

PART 2: PRINT or TYPE name of individual requesting record and his/her current mailing address.

Relationship to Person

Name: ___________________________________________________Named on Record: ______________________________________

Address:_________________________________________________________________________________________________________

City:__________________________________________________________________ State: __________________ Zip:____________

Daytime phone number: (______) _______ - _________ E-mail Address:_________________________________________

Intended Use of Certified Copy: Travel (Date needed: ________________________) Social Security/Benefits School

Employment Driver’s License Other (List reason: ___________________________________________________________)

PART 3: PRINT or TYPE information below regarding person named on requested record: Number of copies: ________

Name at Birth: ___________________________________________________________________________________________________

If name has changed since birth due to adoption, court order,

or any reason other than marriage, please list that name here: ____________________________________________________________

Date of Birth:________________________________________________ Age Now: __________ Sex: Male Female

(Month/Day/Year - Records available from 1906 to the present)

Place of Birth: ___________________________________________________________________ Hospital: _______________________

(County) (City/Boro/Twp. In Pennsylvania)

Full Maiden Name of Mother: _______________________________________________________________________________________

Full Name of Father: ________________________________________________________________________________________________

PART 4: BIRTH: $10.00 each. If fee is required, make check/money order payable to: VITAL RECORDS.

Fees will be waived for individuals who served or are currently serving in the Armed Forces and their dependents (complete the following):

Armed Forces Member’s Name: ________________________________________Service Number:________________________________

Relationship to Armed Forces Member: _________________________Rank and Branch of Service:_________________________________

PART 5: VALID GOVERNMENT ISSUED PHOTO ID REQUIRED

Individual requesting record must include a legible copy of his/her valid government issued photo ID that verifies name and

mailing address as listed in Part 2 above.

Examples: State issued driver’s license or non-driver photo ID (if address has been changed, include copy of update card).

If possible, enlarge photo ID on copier by at least 150% (copies of ID will be shredded upon review).

If acceptable ID not available, visit our website at www.health.state.pa.us/vitalrecords for further information.

Mail with self-addressed, stamped envelope to: Have you?

DIVISION OF VITAL RECORDS (ATTN: BIRTH UNIT)

Signed your name in Part 1 (do not

101 SOUTH MERCER STREET

print)

PO BOX 1528

Listed your name and current mailing

NEW CASTLE, PA 16103 address in Parts 2 and 5

Completed all items in Part 3 (enter

Print or type name and address in the space provided below unknown if information unavailable)

(must agree with name and current address in Part 2 and ID documentation):

Enclosed payment (or completed Part 4

Name

for waiver of fee)

Enclosed legible copy of ID (must agree

Street

with your name and address in Parts 2

and 5)

City, State, Zip Code

For EXPEDITED ON-LINE ORDERING or additional information, visit our website: www.health.state.pa.us/vitalrecords