Fillable Printable Vital Records Request for Copy of Birth Certificate - Arizona

Vital Records Request for Copy of Birth Certificate - Arizona

Arizona Vital Records Request for Copy of Birth Certicate

Please visit the State Office of Vital Records website www.azhealth.gov for

the following information:

• Fees

• Locations, office hours, and availability of services

• Eligibility requirements and acceptable identification

• Correction, amendment, and registration information

• Download forms

Telephone: 602-364-1300

Apply Online: www.VITALCHEK.com

(Refer to website for their current fees)

CUSTOMER ChECkliST

2 Clear photocopy of the front and back of your valid, signed

government photo ID OR have your signature notarized

2 Proof of relationship enclosed if required (birth certificates,

certified court documents, etc)

2 Sign the application

2 Include self-addressed stamped envelope

2 Correct fee enclosed

PAYMENT iNFOBiRTh CERTiFiCATE iNFORMATiONPERSON REQUESTiNGNOTARY AREA

Today's Date

Applicant's Full Name—Printed

First Middle last

Applicant's Signature—Required

Date of Birth

State (if US) or Country of birth

Town/City of Birth

Mother's/Parent's First Name

Father's/Parent's First Name

Middle

Last Name prior to rst marriage

last

County hospital

Name on Birth Certicate

First Middle last

Mailing Address

Street City State Zip

# of Certied Copies Requested Purpose of Request Payment Method

Sex

2 Male 2 Female

Do you belong to an Arizona Tribe?

2 Yes 2 No

if yes, please specify tribe.

Daytime Telephone Number Email Address

Your Relationship to Person on Certicate—Check One *PROOF of relationship MUST be provided if you are NOT named on the certicate.

2 Parent 2 Self 2 Brother/Sister 2 Grandparent 2 Legal Guardian 2 Spouse 2 Gov't Agency 2 Other

State of County of

On this day of , 20 before me personally appeared

(name of signer), whose identity was proven to me

on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who

acknowledges that he/she signed the above document.

Notary Signature My Commission Expires

Afx Seal/Stamp Here

Payment information

Card Number _______ - _______ - _______ - _______ Card Expiration Date / 2 Visa 2 MC

Signature of Cardholder— Must provide photocopy of valid government issued identication if cardholder is not the applicant. Amount to be Charged

For Ofce Use Only—State File Number/Serial Number

VS-11 (05/15)

Request iD

iNFO

PARTICIPATI NG OFFICE LOCATIONS (06/15)

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PARTICIPATING OFFICE LOCATIONS

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The State Office of Vital Records does not provide walk-in service for birth and death certificate issuance. Services available at

the State Office of Vital Records by appointment only are delayed birth registration, adoptions, foreign born, putative father, and

amendment s and corrections for births that occurred prior to 1997 and deaths th at occurred prior to 2008.

For walk-in customer service, please visit your nearest local county vital records office providing walk-in service as listed below.

Please note payment types accepted at various office locations: Cash (C) - in person only, Money Order/Cashier's Check (MO),

Personal Check (PC), Credit Cards (CC), Debit Cards (DC).

Please visit http://azdhs.gov/vital-records/ or call for the most current fee schedule for each office.

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State Office of Vital Records

1818 W. Adams St.

Phoenix, AZ 85007

(602) 364-13 00

Mail to: PO Box 6018

Phoenix, AZ 85005

Certified Copies of Birth and Death

Certificates are Available by Mail Onl y

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Apache County Public Health Services District

75 W. Cleveland St.

Johns, AZ 85936

(928) 337-76 68

(MO) (C)

Mail to: PO Box 697

St. Johns, AZ 85936

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Cochise County Health Department

4001 E. Foothills Dr.

Sierra Vista, AZ. 85635

(520) 803-39 25

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Coconino County Health Departme nt

2625 N. King St.

Flagstaff, AZ 86004

(928) 679-72 72

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Gila County Health & Emergency Services

Office of Vital Records

5515 S Apache Ave., Ste. 100

Globe, AZ 8550

(928) 402-88 11

Graham County Health Department

820 W. Main

Safford, AZ 85546

(928) 428-44 41

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Greenlee County Health D ep artment

Office of Vital Registration

253 5th St.

Clifton, AZ 85533

(928) 865-26 01

(C), (MO)

Mail to: PO Box 936

Clifton, AZ 85533

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La Paz County Vital Records Office

1112 Joshua Ave, Ste. 206

Parker, AZ 85344

(928) 669-11 00

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Maricopa County

Office of Vital Registration

3221 N. 16th St., Ste. 100

Phoenix, AZ 85016

Office of Vital Registration

3003 W. Thomas Rd., Ste. 200B

Phoenix, AZ 85017

Office of Vital Registration

4419 E. Main St., Ste. 105

Mesa, AZ 85205

Office of Vital Registration

1850 N 95th Avenue, Ste. 182

Phoenix, AZ 85037

(602) 506-68 05 (C)

(MO) (CC)

For all Mail: P.O. Box 2111

Phoenix, AZ 85001

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Mohave County Public health

County Administration Building Drop

Box in lobby:

700 W. Beale St.

Kingman, AZ 86401

Mail to: PO Box 7000

Kingman, AZ 86402

(928) 753-07 48 (C)

(MO)

Certified Copies of Birth Certificates are Available

by Mail Onl y or Drop Box

Navajo County H ea lth Department

117 E. Buffalo St.

Holbrook, AZ 86025

(928) 524-47 50

(MO)

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Pima County Health Department

Vital Records Office

3950 S. Country Club Road Ste. 100

Tucson, AZ 85714

(520) 724-79 32

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Pinal County Health Department

36235 N. Gantzel Rd.

San Tan Valley, AZ 85142 (520)

886-4670 / 1-800-231-8499 (C)

(MO) (CC)

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Pinal County Health Department

41600 West Smith-Enke Rd.

Bldg. 15

Maricopa, AZ 85138

(520) 866-42 61 / 1-800-231-8499

Mail to: PO Box 2945

Florence, AZ 85132

(Funeral Homes Only)

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Santa Cruz County Health Services

2150 N. Congress Dr. Ste. 115

Nogales, Arizona 85621

(520) 375-79 00

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Yavapai County Health Department

1090 Commer c

e Dr.

Prescott, AZ 86305

(928) 771-31 25

Certified Copies of Birth Certificates and Death

Certificates are Available by Mail Only

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Yuma County Health Services

Vital Records Department

2200 W. 28th St.

Yuma, AZ 85364

(928) 317-45 30