Fillable Printable Birth Certificate Request - Washington D.C.
Fillable Printable Birth Certificate Request - Washington D.C.
Birth Certificate Request - Washington D.C.
Birth Certificate Request*
Vital Records Division
For District of Columbia Occurrences Only
RESTRICTION: Family or legal representatives only. See page two for details
Mail-In Form
(See below for Instructions)
1. Certificate Holder's Name:
(First) (Middle) (Last)
2. Birth Date:
/ / (mm/dd/yyyy)
3. Sex:
Male Female
4. Hospital:
5. City: Washington, DC
6. Father's Name:
(First) (Middle) (Last)
7. Mother's Maiden Name:
(First) (Middle) (Maiden)
8a. Number of Original Certificate Forms Requested:
$23.00 each
Total Cost: $
8b. Total Amount Enclosed:* *
$
9. Relationship to Certificate Holder:
Self Mother Father Other
10. Signature of Requester:
_
____________________________________
11. Date:
_
________/_________/_________ (mm/dd/yy)
Mail Certificate(s) to:
12. Name:
13. Address:
14. City/State/Zip Code::
15. Day Phone: (Required)
* Copy of Requester's Photo ID Required.
If record is not located a "Certificate of Search" will be issued.
**Beginning January 1, 2009, all mail-in requests must include a stamped self addressed No. 10 (4 1/8" x
9 1/2") business size return envelope.
**The DC Treasurer requires that all checks have an address imprinted on them to be accepted for
deposit. Starter checks are not accepted.
Instructions to be completed:
1. Print, sign, enclose requestor's photo ID and date the form
2. Enclose check or money order payable to DC Treasurer
3. Mail to: Department of Health
Vital Records Division
899 North Capitol Street, NE, 1st Floor
Washington, DC 20002
(202) 442-9303
Birth Application Instructions
The birth certificate request form contains 12 questions. A separate copy of the request form should be
completed for each person whose birth record is being requested. However, multiple copies of a single birth
record may be requested on the same form.
Items 1-7: Personal information about the certificate holder.
Item 8a: Please indicate the total number of original form certificates that you are requesting. To calculate the
total cost, multiply the number of requested certificates by $23.
The DC Vital Records Division does not process online orders
. For your convenience, you can process online
requests through VitalChek Network, Inc., an independent company that Vital Records has partnered with to
p
rovide you this service. VitalChek can be reached either through its website www.vitalchek.com or by phone
at 1 (877) 572 6332. An additional fee is charged by VitalChek for using this service, and all major credit cards
are accepted including American Express, Discover, MasterCard or Visa.
Item 8b: Please indicate the total amount of money that you are enclosing. If you send your request by mail,
please enclose a check or money order payable to the DC Treasurer. The DC Treasurer requires that all
checks have an address imprinted on them to be accepted for deposit.
Item 9: The relationship of the requester to the certificate holder.
Items 10-11: The person who is requesting the certificate(s) must sign and date the request and enclose a
p
hotocopy of his or her official picture identification card.
Items 12-15: Information about the designated recipient of the certificate(s).
After you have printed out and signed your request, mail it with your payment to:
Department of Health
Vital Records Division
899 North Capitol Street, NE, First Floor
Washington, DC 20002
(202) 442-9303
If record is not located a "Certificate of Search" will be issued.
Restriction on Access to Birth Certificates: Pursuant to D.C. Official CodeSec. 7-220, the Vital Records
Division may issue a certified copy of a birth certificate ONLY to an applicant having a direct and tangible
interest in the requested birth certificate.
NOTE: This form should be used ONLY
by the registrant, a member of his/her immediate family, his/her
guardian or legal representative.
