Fillable Printable Birth Certificate Application - Minnesota

Birth Certificate Application - Minnesota

Page 1 of 2 REV 03/2015

Birth Certificate Application

The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7

and Minnesota Rules, part 4601.2600. If you do not complete all fields, the application may be returned.

Birth Record Information

First Name Middle Name Last Name

Date of Birth

☐Male ☐Female

City and County of Birth

Mother’s First Name Middle Name Maiden Name

Father’s First Name Middle Name Last Name

Requester Information

Name Date of Birth

Mailing Address – Street Apt/Unit # City State ZIP

Daytime Phone Email

What is your relationship to the subject of the record (tangible interest)? You must check one.

☐

I am the subject of the record

☐

I am the child of the subject

☐

I am the spouse of the subject

☐ I am the parent ☐I am the grandparent of the subject ☐I am the grandchild of the subject

☐ I am the party responsible for filing the birth record

☐ I am the legal custodian, guardian or conservator of the subject (you must include a certified copy of a court order showing this

relationship)

☐

I am the health care agent of the subject (you must include the health care agent power of attorney)

☐

I am a personal representative and the certified copy is required for the administration of the estate

☐ I am a successor of the subject as defined my MN statutes, section 524.1-201, and the subject is deceased

☐

I have documentation that the record is necessary for the determination or protection of personal or property rights (you must

submit documentation showing this relationship)

☐ I represent an adoption agency and the record is needed to complete a confidential post-adoption search (you must include a

copy of your employee ID)

☐

I am an attorney and I have attached proof of my licensure

☐ I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified copy)

☐

I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to perform its

authorized duties (you must include a copy of your employee ID)

☐ I am a representative authorized by a person listed above (you must include a notarized statement from a person listed above)

Signature and Notary (application must be signed in front of a notary if applying by mail, fax, or email)

I certify that the information provided on this application is accurate and complete to the best of my knowledge.

Requester Signature

Signed or attested before me on: _______ day of ___________________, 20_______

Notary Stamp/Seal

Notary Public Signature

My Commission Expires:

PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1

year in jail or a fine of up to $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).

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Birth Certificate Application

Requester Name:

Fee and Payment Information

Item

Number

requested

Fee Total

One birth certificate 1 $26 $26

Additional certificate(s) for the same birth record (optional) $19 each

Expedite fee (optional) – This is an additional fee that will place your request

ahead of non-expedited requests.

$20

Overnight shipping delivery (optional) – This is an additional fee that applies only

to the method of delivery.

☐

Please check here to require a signature for delivery. If you do not check this

box, no signature will be required for delivery.

Overnight shippers will not deliver to P.O. boxes or A.P.O. addresses.

$16

Total amount submitted or to be charged to credit card:

(This amount must be at least $26.)

Type of payment:

☐

Credit Card

☐

Money order

☐

Check

If paying by credit card (MasterCard/VISA/Discover):

Name on card Card number Expiration date 3-digit security code

If paying by check or money order (make payable to Minnesota Department of Health):

Check/money order number

Checks returned for non-payment will be charged a $30 fee according to Minnesota Statutes, section 604.113, subdivision 2 and civil

penalties may be imposed.

Send application and payment:

By FAX to 651-201-5740

By MAIL to:

Minnesota Department of Health

Central Cashiering – Vital Records

PO Box 64499

St. Paul, MN 55164-0499

If you submit this application to a local issuance office, overnight delivery may not be an option. All payment types may not be

accepted. Call the local issuance office before sending your application to confirm payment types and return mail options.