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:

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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

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

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.

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