Fillable Printable Mail Application for a Certified Copy of a Birth Certificate - Texas

Mail Application for a Certified Copy of a Birth Certificate - Texas

OFFICE USE ONLY

Cert #

DOCUMENT CONTROL #

By______________

MAIL APPLICATION FOR

BIRTH OR DEATH RECORD

OFFICE USE ONLY

Remit No.

By______________

ZZ 708-153

PLEASE PRINT. INCLUDE A PHOTOCOPY OF YOUR VALID PHOTO ID WHEN SENDING THE REQUEST.

Birth Certificates Death Certificates

Type Cost X # of copies= Total Type Cost X # of copies= Total

Certified Copy $22 Certified Copy (1 copy) $20

Heirloom-Flag $60 Additional copies $3

Heirloom-Bassinet

$60

(optional) $8.00 Lone Star OR $19.95 USPS

Express return delivery

(optional) $8.00 Lone Star OR $19.95 USPS

Express return delivery

Total (Check or money order payable to DSHS)

I wish to make a voluntary contribution of $5.00 to promote healthy early childhood by supporting the Texas Home

Visitation Program administered by the Office of Early Childhood Coordination of Health and Human Services.

1. Full Name of

Person on Record

First Name Middle Name Last Name

2. Date of Birth or

Death

Month Day Year 3. Sex

4. Place of Birth or

Death

City or Town County State

5. Full Name of

Father

First Name Middle Name Last Name

6. Full Maiden

Name of Mother

First Name Middle Name Maiden Name

7. YOUR NAME 8. TELEPHONE #

( ) -

EMAIL ADDRESS

(MON-FRI 8:00-5:00)

9. MAILING ADDRESS

STREET ADDRESS CITY STATE ZIP

10. RELATIONSHIP TO PERSON NAMED IN ITEM 1: 11. PURPOSE FOR OBTAINING THIS RECORD:

12. WILL THIS RECORD BE USED TO OBTAIN A PASSPORT, FOR IMMIGRATION OR FOR THE INDIAN REGISTRY? YES NO

13. ADDITIONAL INFORMATION FOR DEATH CERTIFICATE: BIRTHDATE

BIRTH PLACE

I authorize mailing to the address below instead of my mailing address. I have verified that the address below will receive my order.

NAME STREET ADDRESS

CIT

STATE

ZIP

WARNING: IT IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALTY FOR KNOWINGLY MAKING A FALSE

STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STATEMENT IS 2 TO 10 YEARS IMPRISONMENT AND

A FINE OF UP TO $10,000. (HEALTH AND SAFETY CODE, CHAPTER 195, SEC. 195.003)

Your Signature

Date of Application

APPLICATIONS WITHOUT SIGNATURE OF APPLICANT WILL NOT BE PROCESSED.

MAIL THIS APPLICATION, PAYMENT AND A PHOTOCOPY OF YOUR VALID PHOTO ID (APPLICATIONS WITHOUT PHOTO ID WILL NOT BE

PROCESSED) TO:

Texas Vital Records

Department of State Health Services

P.O. Box 12040

Austin, TX 78711-2040

VS-142.3 Rev. 12/2013

For any search of the files where a record is not found, the searching fee is not refundable or transferable.