Fillable Printable Request for a Certified Copy of a Birth Record from the State - Connecticut
Fillable Printable Request for a Certified Copy of a Birth Record from the State - Connecticut
Request for a Certified Copy of a Birth Record from the State - Connecticut
STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
VITAL RECORDS SECTION, CUSTOMER SERVICES
410 CAPITOL AVENUE, MS #11VRS
P.O. BOX 340308
HARTFORD, CT 06134-0308
*If adopted, please provide your adoptive name and adoptive parents’ information
. Birth Request REV 5-12
*If the requester had a legal name change, please provide a copy of the court documents authorizing the name
change.
REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE STATE
FEE: $30.00 PER COPY. REMIT M ONEY ORDER MADE PAYABLE TO: ‘TREASURER, STATE OF CT’
PLEASE PRINT
FULL NAME ON CERTIFICATE*:___________ __________________ _________ _________ _________ _________ _________ ______
FIRST MIDDLE LAST NAME
DATE OF BIRTH: ____ ____/________/_____ ___ PLACE OF BIRTH: ___________ _________ _________________________
MONTH DAY YEAR TOWN/CITY
FATHER’S FU LL NAME: _______________ _________ _________________________________ _________ _________ _________ ____
FIRST MIDDLE LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________
FIRST MIDDLE LAST NAME
PERSON MAKIN G THIS REQUE ST:
NAME: ___________ _________ _________ ___________________________________________________________________________
FIRST MIDDLE LAST NAME
ADDRESS: _____________________________________________________________________________________________________
NUMBER/STREET/UNIT #
TOWN/CITY: _______________________________________________ ___ STATE: _____________ ZIP CODE: _____________
TELEPHONE NO: ____________________________________ E-MAIL ADDRESS: ______ __________________________ ______
SIGNATURE: X___________________ _________ _________ _________ _________ _________ _________________________________
RELATION TO PERSON NAMED ON CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: ______________________________________________________________________________
CERTIFICATE SIZE:
FULL SIZE WALLET SIZE
TOTAL NUMBER OF COPIES:
NUMBER OF COPIES: __________
The wallet size birth certificate contains less
information than the full size certificate. It
does not satisfy the proof of identification
requirements needed for a passport or driver’s
license.
NUMBER OF COPIES: __________
_______ X $30.00 = $ _______
SEND POSTAL MONEY ORDER ONLY
DO NOT MAIL CASH OR PERSONAL
CHECKS - THEY WILL NOT BE
ACCEPTED.
Attach a copy of the requester’s valid government issued
photo ID or passport below:
Or two (2) forms of the following:
- Social security (SS) card
- Paycheck Stub or a W-2 form showing SS #
- Current school or college photo ID
- Automobile registration
- Copy of utility bill or bank statement showing name and
address
- See our website ct.gov\dph for other forms of ID accepted
Please mail the complet ed request with the following
requirements:
Money order made payable to ‘Treasurer, State of CT’
Current government issued photo ID
(If applicable) verification of relationship to the
registrant (for example, an individual requesting
his/her parent’s birth certificate must provide a
certified copy of his/her own birth certificate).
