Fillable Printable Minnesota Certificate of Birth Application
Fillable Printable Minnesota Certificate of Birth Application
Minnesota Certificate of Birth Application
MINNESOTA CERTIFICATE OF BIRTH APPLICATION
The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
Make sure all boxes are complete or your application may be returned.
PART I: Birth Record Information
FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF BIRTH
SEX
CITY & COUNTY OF BIRTH
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: Requester Information
NAME (PLEASE PRINT)
DATE OF BIRTH
MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O addresses)
CITY
STATE
ZIP
DAYTIME PHONE
EMAIL
PART III: What is your relationship to the subject of the record (tangible interest)? You must check one.
I am the subject of the record
I am the child of the subject
I am the spouse of the subject
I am a parent listed on the record
I am the grandparent of the
subject
I am the grandchild of the subject
I am the party responsible for filing the birth record
I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a court order
showing this relationship)
I am the health care agent of the subject (you must submit a health care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate (you must submit
a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must
include a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I have documentation that the record is necessary for the determination or protection of personal or property rights
(you must submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please
submit a copy of your employee ID)
I am an attorney and I have attached proof of my licensure
I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified
copy)
I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to
perform its authorized duties (please submit a copy of your employee ID)
I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a
person listed on the birth record)
PURPOSE FOR YOUR REQUEST (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
REQUESTER’S SIGNATURE
Signed or attested before me on: _______ day of ____________________, 20_______
NOTARY STAMP/SEAL
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES:
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year
in jail or a fine of up to $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
MINNESOTA CERTIFICATE OF BIRTH APPLICATION
REQUESTER’S NAME:
PART V: Fee and Payment Information
Item
Number
requested
Fee per
item
Total
One birth certificate
1
$26
$26
Additional birth certificate(s) for the same person
$19 each
Total amount submitted:
(This amount must be at least $26.)
Type of payment:
Money order
Check
If paying by check or money order (make payable to Beltrami County License Center):
Check/money order number:
Checks returned for non-payment will be charged a $30 fee according to Minnesota Statutes, section 604.113, subdivision 2
and civil penalties may be imposed.
Mail application and check/money order to:
Beltrami County License Center
Beltrami County Administration Building
701 Minnesota Ave NW Suite 100
Bemidji, MN 56601
