Fillable Printable Request for a Certified Copy of a Birth Record from the Town - Connecticut
Fillable Printable Request for a Certified Copy of a Birth Record from the Town - Connecticut
Request for a Certified Copy of a Birth Record from the Town - Connecticut
*If adopted, please provide your adoptive name and adoptive parents’ information. Birth Request form from Town Rev. 5-2012
*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 TOW N
Mail this request to the Town Vital Records office. For the address and phone number of Town Vital
Records offices in Connecticut, please refer to the Town website or the DPH website at www.ct.gov/dph.
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:
$20.00 EACH
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 a
driver’s license.
$15.00 EACH
NUMBER OF COPIES: __________
_______ X $20.00 = $ _______
_______ X $15.00 = $ _______
TOTAL: $ _______
Send Postal Money Order Only. Do
Not Mail Cash or Personal Checks.
Atta ch a copy of the reques ter’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 that contains the SS #
- Current school or college photo ID
- Automobile registration
- Copy of utility bill or bank statement showing name and
address
- See website ct.gov\dph for other forms of ID accepted
Please mail the completed request with the following required
documents :
Money order made payable to City/Town (refer to the
Town or DPH website cited above)
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).
