Fillable Printable Application for Search and Certified Copy of Birth Record - Indiana

Application for Search and Certified Copy of Birth Record - Indiana

APPLICATION FOR SEARCH AND CERTIFIED COPY OF BIRTH RECORD

State Form 49607 (R7 / 11 -14)

Approved by State Board of Accounts, 2014

INDIANA STATE DEPARTMENT OF HEALTH

BIRTH RECORDS IN THE STATE VITAL RECORDS OFFICE BEGIN WITH OCTOBER 1907. Prior to October 1907, records of birth are

filed ONLY with the local health department in the county where the birth actually occurred .

FEES ARE ESTABLISHED BY LAW (IC 16-37-1-11 and IC 16-37-1-11.5). Each search for a record costs $10.00. The fee is non-refundable.

Included in one search is a five (5) year period: the reported year of birth and, if the record is not found in that year, the two (2) years before

and after. A certified copy of the record, if found, is included in the search fee. Additional copies of the same record purchased at the same time

are $4.00 each. Amendments made to the record are an additional $8.00.

WARNING: FALSE APPLICATION, ALTERING, MUTILATING, OR COUNTERFEITING INDIANA BIRTH CERTIFICATES IS A

CRIMINAL OFFENSE UNDER IC 16-37-1-12.

IDENTIFICATION IS REQUIRED according to IC 16-37-1-7 (SEE REQUIREMENTS AND ACCEPTABLE DOCUMENTATION LIST).

Requests for birth certificates sent without proper identification will be returned to the requester without processing. Please complete all

items below as required pursuant to IC 16-37-1-10 (a):

Full Name at Birth

Could this birth be recorded under any other name? If Yes, Please Give Name.

Has the person ever been adopted? If Yes, Please Give Name AFTER Adoption.

Place of Birth: City Place of Birth: County

Name of Hospital

Date of Birth (Month, Day, Year) Is this Person Deceased? (Please Check One) YES NO UNKNOWN

If YES which state, if known _________________________________

Full Name of Parent 1 (If adopted, Give Name of Adopted Parent.)

Full Name of Parent 2 including Maiden Name (If adopted, Give Name of Adopted Parent.)

Purpose for which record is to be used

Your Relationship to the Individual Named on the requested certificate

Total Certificates

Standard Size ________________ (Passport Acceptable) Long Form ________________ (Statistical Version)

(Please note: if a long form is unavailable, standard size will be sent.)

Is this certificate for an Apostille?

(Please Check One)

Yes No

Delivery Preference (Please call agency for current express delivery rate.)

Regular Mail

Express Courier, Signature upon delivery required

Total Fee

Print Name of Applicant Signature of Applicant

Mailing Address (Number, Street, City, State, ZIP Code) ADDRESS MUST MATCH THE IDENTIFICATION PROVIDED.

Daytime Telephone Number (including Area Code) Today’s Date (Month, Day, Year)

Send this application(s) with a check or money order payable to the Indiana State Department of Health, along with copy of Government

State, or Military valid identification and,/or required documentation to: Vital Records, Indiana State Department of Health, P O Box 7125,

Indianapolis, IN 46206-7125. Please note: If identification does not match the address provided, your request

will not be processed.

FOR OFFICE USE ONLY

Date received (Month, Day, Year) Receipt Number Volume Number

Certificate Number Application Number Initials of Verifier