Fillable Printable Application for Certified Copy of Kansas Birth Certificate

Application for Certified Copy of Kansas Birth Certificate

Address: City/State: Zip:

Email:

Self Father Paternal Uncle

Mother Brother Maternal Uncle

Sister Son Paternal Aunt

Current Spouse

Daughter Maternal Aunt

Date of Birth: Race:

Sex:

$Total:

Adopted?

Yes No

1) This request form must be completed.

Type/ID #

2) Enclose a copy of both front and back of a current legal photo ID

(see back for list of acceptable ID's)

3) Enclose appropriate fees

4) Person requesting the certificate must sign above

Amount given

Chg provided

5) If submitting by mail, enclose a self-addressed stamped envelope

*Request will be returned if the above steps are not completed correctly

Walk-in Hours:

Mon-Fri

9:00 a.m-4:00p.m.

VS-235 3/15

Birthplace of Father:

Station/# of apps __________________________ Exp __________________

If certificate name has changed since birth other than adoption

or marriage, please list changed name here:

Is request for record before adoption?

Application for Certified Copy of Kansas Birth Certificate

* IF THE CERTIFICATE IS NOT LOCATED, A $15.00 FEE MUST BE RETAINED BY THIS DEPARTMENT FOR THE RECORD SEARCH

Make checks or money orders payable to Kansas Vital Statistics. For your protection, do not send cash.

Hospital of Birth:

Full Maiden name of Mother:

Full Name of Father:

Fees

K.A.R. 28-17-6 requires the following fee(s).

The correct fee must be submitted with the request. The fee for certified copies of birth certificates is $15.00 for each certified copy. This fee allows

a 5-year search of the records, including the year indicated plus two years before and two years after, or you may indicate the consecutive 5-year

period you want searched. You may specify more than one 5-year span, but each search will cost $15.00.

Birth Information

* PLEASE NOTE BIRTH CERTIFICATES ARE ON FILE FROM JULY 1, 1911 TO PRESENT

(person requesting the certificate)

Other (specify)

Phone Number:

Name on ďŝƌƚŚCertificate:

Current Age of this person:

Wallet cards are no longer available as of July 1, 2012

Birthplace of Mother:

Today's Date:

Date of Death:

Name of Requestor:

*IM P ORTANT: The per s on r eques ting the v ital r ec ord must submit a copy of their identification. S ee li s t on r ev er s e side.

Relationship to person on the Certificate? (Check one)

Reason for Request (PLEASE BE SPECIFIC):

Signature of Requestor:

Paternal Grandparent

Legal Guardian(submit custody order)

Place of Birth:

City, County, State ( must be in Kansas )

*Requirements-Read before turning in application

OFFICE USE ONLY

INITIAL

Payment Type CASH CHECK CCARD MO

Maternal Grandparent

Office hours:

Kansas Office of Vital Statistics

Number of copies ordered: $15 per certified copy

Mon-Fri 8:00a.m.-5:00 p.m.

1000 SW Jackson Suite 120

Phone: 785-296-1400

Topeka, KS 66612-2221

Name Change

Provide before adoption name (below)

Adoption Information

(If Applicable)

◦ Aunts/Uncles

◦ Must be age 18 or older

◦ VA Card (with intact photo)

◦ Current Spouse

◦ Adult Children

◦ Grandparents

Identification

By State law, vital records filed with this office are not open for public

inspection and the requestor must meet eligibility requirements -- must be

named on the record, an immediate family member, or someone who can

provide legal proof the record is necessary for the determination of personal or

property rights. [K.S.A. 65-2422d]

◦ Parents

Please make a copy of one of the following documents and send

with the application. All documents MUST be signed, current

and valid. All Identification must have both sides and be able to

be read.

◦ Photocopy of Government Issued Driver's License, Military ID,

State ID card, Valid Passport and Visa's. (Not the credit/debit

card)

◦ Permanent resident card

◦ Refugee Travel Document

◦ Certificate of Naturalization (with intact photo)

◦ Voter's registration card (Countries outside of the U.S.)

◦ Alien registration receipt card

◦ Employment authorization card

◦ Re-entry permit

◦ Inmate ID of Requestor(along with a memo completed and signed by a counselor or parole officer)

◦ Niece/Nephew

Who's Eligible to Obtain Most Certificates: Must provide ID and proof of direct

interest

Requestor's current ID required To Get a Certificate:

Eligibility

ONE form of Primary Documentation required from list below

◦ Utility Bill with current address of Requestor and company letterhead with company name and address; not handwritten

◦ Current Pay Stub (must include your name, social security number plus name and address of business; not handwritten)

◦ Social Security card (must be signed by card holder)

◦ Bank Statement with Requestor's current address

◦ Car Registration or Title with Requestor's current address

* PLEASE NOTE MATRICULAS ARE NOT AN ACCEPTABLE FORM OF

If legal guardianship has been established through the courts, please provide a

copy of the guardianship papers.

◦ Resident Alien card

◦ Siblings

◦ Concealed Carry handgun license

If you do not have a government issued photo ID, you must send photocopies of any two of the following: *Photocopies must be

of the complete document, able to be read and be the Requestor's with current address

◦ Temporary Driver's License

◦ Valid insurance card or policy of Requestor

◦ Valid health insurance card or policy of Requestor

◦ Parole document (book sheet) of Requestor

◦ Bureau of Indian Affairs Tribal ID card of Requestor

1) Fees expire 12 Months from the date of the request.

2) MULTIPLE REQUESTS FOR DIFFERENT RECORDS MAY BE HANDLED AND MAILED SEPARATELY.

WARNING: COPYING, ALTERING, or FRAUDULENT ACTIVITY PROHIBITED

Except as authorized by the Uniform Vital Statistics Act, no person shall prepare or issue any certificate (vital record) which purports to be an

original, certified copy or abstract or copy of a certificate [K.S.A. 65‑2422d.(g)]. Vital records identity theft related to obtaining certificates or

making, counterfeiting, altering, amending any certified copy of a vital record with the intent to sell or obtain for any purpose of deception a

certified copy of a vital record is a severity level 8, nonperson felony. [K.S.A. 21-3830a (d) and K.S.A 21-3830a (e)].

◦ Letter from employer (with Requestor's current address)

◦ U.S. Voters registration card of Requestor

Adoption

When an adoption has occurred, the biological family may not have a legal right to the adoptee’s record nor may the adoptee have a legal right to

the biological family’s records.

◦ Filed Income Tax of Requestor with current address

◦ Letter to Requestor from Social Service Agency/Health Department or other government agency with current address

◦ Hospital or Health agency bill (with current address) of Requestor

◦ Court Documents of Requestor

◦ W-2 from Employer (with Requestor's current address)

Read: IMPORTANT MISCELLANEOUS INFORMATION

Detailed Information