Fillable Printable Birth Record Order Form - Oregon
Fillable Printable Birth Record Order Form - Oregon
Birth Record Order Form - Oregon
ARE YOU ORDERING
A VITAL RECORD BY MAIL?
No record will be provided unless you:
Sign the form
AND
Include a photocopy of your ID
See form for details.
Thank you!
Oregon Vital Records
In accordance with law — ORS 432.380, only the person named on the record,
immediate family members, legal representatives and government agencies are eligible
to access birth records. For all others, access to birth records is restricted for 100 years.
Legal guardians must enclose a copy of the legal document. If you are not eligible,
enclose a written permission note with a notarized signature of an eligible person.
Oregon Birth Record
ORDER FORM
45-13A (12/14)
Send to:
OREGON VITAL RECORDS
PO BOX 14050
PORTLAND OR 97293-0050
Make checks/money orders payable to:
OHA/Vital Records
PLEASE DO NOT SEND CASH
Checks/money orders in U. S. Dollars
Center for Health Statistics
Number of certied records requested.
$20 rst record/$15 each additional copy
of the same record ordered at the same time.
1. Full name on record:
ENTER YOUR MAILING ADDRESS
THIS SECTION WILL BE DETACHED AND USED AS A MAILING LABEL
2. Date of birth: 3. Sex: 4. Place of birth: OREGON
14. cPerson ordering: Attach legible photocopy of current, valid ID or legal
representative document. See back of form for alternative ID options.
13. City/State/ZIP:
12. Your address:
11. Name of person ordering:
8. Reason for needing record:
7. Your relationship to person named in line 1:
15. Required signature of person ordering:
6. Father’s full name:
(rst) (middle) (last)
(
or Parent #2
)
5. Mother’s full legal birth name:
(rst) (middle) (lastnameatmother’sbirth/maidenname)
(
or Parent #1)
9. Daytime telephone number:
10. Email:
(mm/dd/yyyy) (M or F) (city) (county)
QUANTITY
Non-
SufcientFunds(NSF)
check processing policy: In the
event that your check is returned
unpaidforinsufcientoruncollected
funds, we may present your check
electronically. In the ordinary
course of business, your check will
not be provided to you with your
bank statement, but a copy can be
retrieved by other means. A $25.00
penalty may be assessed for NSF
checks per ORS 30.701(5).
See second page of form for
ordering options and processing
times. Information is also available
on our Web page at:
www.healthoregon.org/chs or by
calling 971-673-1
190.
NRL/ref. issued:
Full issued:
Follow-up: Computer copy:
Refund: $
Check #:
File date:
Amendment fee:
Film (P)
Computer
Indexes
Index (P)
DF/CO
1
2
Film
Out/state
Uncompleted
No record
Excess fee
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
Certicatenumber:
WARNING
:
Providing false information is a felony under ORS 432.993.
$20.00 FOR THE FIRST RECORD; $15.00 FOR EACH ADDITIONAL COPY OF THE
SAME RECORD ORDERED AT THE SAME TIME. The $20.00 fee is non-refundable
once the search for the record has been completed. Administrative Rule 333-011-0340(3).
This form available in alternative formats. See back for details.
(rst) (middle) (last)
Name
Street
City State ZIP
(maiden name
)
This document can be provided upon request in an alternate format for individuals
with disabilities or in a language other than English for people with limited English skills.
To request this publication in another format or language, contact 971-673-1180 (voice)
or 971-673-0372 (TTY), or fax 971-673-1203.
Alternative identication you can send with your mail order.
If you don’t have a valid driver’s license, ID card or passport, send photocopies of three (3) different documents
that include both your name and current address. Suggested documents are listed below. If you are mailing your
order, make photocopies of the documents and include them with your order form.
Documents must be dated within the last 30 days and show current mailing address where record will
be mailed.
Documents such as:
• Utility bill (for example, telephone, gas, electric, water, garbage removal) or other bill;
• Insurance statement, medical statement or paycheck stub,
must have current mailing address and can be no more than 30 days old.
Other documents such as:
• Court or parole documents;
•ValidworkID,unemploymentstatement,foodstamporotherbenetcards(copybothsides);
•Permitforrearms,shing,huntingorotherlicense;
• Vehicle registration, title or insurance statement,
may be used. However, expired documents are unacceptable. For more information on
acceptable documents, go to www.healthoregon.org/chs, click on “Information Needed
to Order,” and scroll down to “Acceptable Proofs of Identity.”
If you have no ID or other documents, an immediate family member can provide ID and order the record.
Records may also be released to a legal representative of a family member or sent directly to a government agency.
How long does it take to receive a record ordered by mail? Processing times vary between three and four
weeks, depending on seasonal workload. To ensure fast processing for mail orders, use a money order instead
of a personal check. Payment by personal check may delay processing by three weeks if the check is on a new
account, is a temporary check, does not include a printed name or address, or has a change to the printed name
oraddress.Ifanamendmentisbeingprocessedortherecordisnotonle,orIDorinformationismissingorin
error, expect an additional delay of two to four weeks.
Order in person and receive the record within 30–45 minutes. Cost: $23.25 for one record, including
security fee. Fees are not refundable after orders are submitted.
StateVitalRecordsOfce:800NEOregonStreet,Suite205,Portland,OR97232-2187
OfceHours:8:00a.m.to4:30p.m.,MondaythroughFriday.
Orders must be submitted by 4:00 p.m. to receive the same day.
Ordering in person is limited to immediate family members of the person named on the record. Orders are
placed at self-service kiosks. The identity of the applicant will be screened using Social Security number and
date of birth. The cost of each screening is $3.25. Persons ordering must show valid ID or provide alternative
documents. In some cases, proof of relationship may be required if the person ordering does not share the last
name of the person on the record and is not clearly a family member. Payment by credit or debit card, cash,
money order or electronic funds transfer (EFT) of a personal check is accepted.
Order online: www.vitalchek.com at any time. Cost: $36.50 for one record shipped by regular mail.
Order by telephone through VitalChek: 1-888-896-4988, 24 hours per day, 7 days per week, except for major
holidays. Cost is $38.45 for one record shipped by regular mail. Fees are not refundable. All major credit/
debit cards accepted. Orders are processed through the VitalChek Network. The fee includes $18.45 per
order to cover vendor, security and expedite fees. Overnight shipping available for an additional fee that varies
depending on the vendor and place of delivery. Records will be mailed/shipped within two working days of
receipt unless a record problem is discovered. Shipments can be delayed for missing or incorrect information,
or if records are still being registered or amended.
45-13A (12/14)
