Fillable Printable Birth Certificate Application - NYC
Fillable Printable Birth Certificate Application - NYC
Birth Certificate Application - NYC
Office of Vital Records
125 Worth Street, CN-4, Room 133
New York, N.Y. 10013-4090
PLEASE PRINT YOUR MAILING AND CONTACT INFORMATION CLEARLY BELOW
NAME
STREET ADDRESS
CITY
DAYTIME
PHONE
NUMBER
STATE
APT. NO.
ZIP CODE
VR 67 (Rev. 01/14)
Area CodeTelephone Number
E-MAIL
ADDRESS
1. LAST NAME ON BIRTH CERTIFICATE2. FIRST NAME
14. CUSTOMER SIGNATURE AND DATE
SIGNATURE: DATE:
15. CUSTOMER COMMENTS/ADDITIONAL INFORMATION
6.BOROUGH WHERE BORN
5. NAME OF HOSPITAL OR ADDRESS WHERE BORN
12. HOW MANY COPIES
DO YOU NEED?
1
2
3
11. DO YOU NEED A LETTER
OF EXEMPLIFICATION?
YES
NO
13. HOW ARE YOU RELATED TO THE PERSON ON THIS BIRTH CERTIFICATE?
SELF/PARENT/OTHER(please explain)
9. FATHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE
FIRSTLAST
7. MOTHER/PARENT’S NAME PRIOR TO FIRST MARRIAGE (MAIDEN NAME):
FIRSTLAST
3.
FEMALE
MALE
8. BIRTH CERTIFICATE NUMBER (if known)
10. WHY DO YOU NEED THIS BIRTH CERTIFICATE
4a.
IF YOU KNOW THE EXACT DATE OF BIRTH
4b.IF YOU DON’T KNOW THE EXACT DATE OF BIRTH
MM DD YYYYMM DD YYYY
BEGIN
SEARCH
MM DD YYYY
END
SEARCH
SEE BELOW
FOR FEE
INFORMATION
SEEINSTRUCTIONS AND
APPLICABLEFEESBELOW
ANDON BACK
OFFICE USE ONLY
NOTE: Copy of a birth record can be issued only to persons to whom the record of birth relates, if of age, or to a parent or human
service organizations. It is a violation of law to make a false, untrue or misleading statement or forge the signature of another on this
application. Violations are a misdemeanor punishable by a fine of up to $2,000.
FEES
$15 per copy x
_________ copies$
________
Cost of certified copy includes a two consecutive
year search
$3 for each extra year searched x
________ years
$
________
Total Amount Enclosed:
$
________
IF RECORD IS NOT ON FILE, A CERTIFIED “NOT FOUND STATEMENT”
WILL BE ISSUED. CASH IS NOT ACCEPTED BY MAIL OR IN PERSON.
ORDER BIRTH CERTIFICATES QUICKLY AND SECURELY AT WWW.NYC.GOV/VITALRECORDS
DO NOT WRITE IN THIS SPACE
NOTARYPUBLICSEAL
APPLICATIONS SUBMITTED BY MAIL MUST
BE NOTARIZED
STATE OF
COUNTY OF
SUBSCRIBED AND SWORN BEFORE ME:
THIS
______
DAY OF
_______________
, 20
____
NOTARY PUBLIC SIGNATURE
BIRTH CERTIFICATE APPLICATION
(Please Print Clearly)
VR 67 (Rev. 01/14)
3 WAYS TOORDER A NEW YORK CITY BIRTH CERTIFICATE
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Online: Visit www.nyc.gov/vitalrecordsto order using a credit card, debit card, or electronic check.
Online orders are processed within 24 hours on weekdays, and UPS express mail delivery is available.
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Walk-In: Go to 125 Worth Street in Lower Manhattan and use the Lafayette Street (handicapped accessible) or
Centre Street entrances. We are open Monday through Friday 9:00AM–3:30PM. Lines are shortest in the morning.
Please see identification requirements below.
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By Mail: All mailed applications must be notarized. Mail your application to 125 Worth Street, CN-4, New York,
NY 10013. Be sure to include a self-addressed, stamped, envelope with your check or money order payable
to the NYC Department of Health and Mental Hygiene. You must provide a photocopy of Category 1
identification or original copies of identification from Category 2 (see below).
Identification (ID) Requirements to get a Birth Certificate for you or your child.
Category 1: Identity documents. If you order in person you can leave with your short form certificate in most
cases, unless you require a long form certificate.
Provide any of the following, if it includes your photo, your signature and is unexpired:
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Driver’s License or non-driver’s ID from any state or U.S. territory
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Public benefit card
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U.S. or foreign passport
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U.S. certificate of naturalization
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Military ID card
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Employee ID with photo, verifiable employer and recent pay stub
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MTA reduced-fare Metro Card
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Student ID and current transcript from accredited and verifiable institution
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Inmate photo ID with release papers
Category 2: Proof of address. If you do not have any of the above, you may provide proof of address as described
below. Your certificate will be mailed to address on documents provided.
Two different documents dated within the past 60 days, if they show your name and address
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Utility bills (online bills can be downloaded from your provider)
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Letter from a government agency
If you cannot provide Category 1 or 2 identification, please contact Vital Records at [email protected]
.
IMPORTANT BIRTH CERTIFICATEINFORMATION
‚
You can obtain a birth certificate for yourself if you are at least 18 years old, or for your child, with current
identification. Detailed instructions for attorneys submitting requests on behalf of their clients are available
online at www.nyc.gov/vitalrecords
.
‚
Falsifying information, including forging a signature, to obtain a birth certificate is a misdemeanor and violators
may also be subject to a fine of up to $2,000 per violation.
‚
Credit cards are not accepted for mail-in orders. If from a foreign country, send an international money order.
‚
Please allow 10–15 days processing time for all long form/vault certificate orders submitted in person.
‚
Processing of mailed applications takes approximately 15 days. Check current times at www.nyc.gov/vitalrecords.
