Application for Copy of Birth Record

Fee: Monroe County - $30.00 / Other Districts - $10.00 per certified copy or No Record Certification

Identification Requirements:

Application must be submitted with copies of either A or B.
(Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.)

A. One (1) of the following forms of valid photo-ID:

• Driver license
• Non-driver photo-ID card
• Passport
• Employment ID

-OR-

B. Two (2) of the following showing the applicant's name and address:

• Utility or telephone bills
• Letter from a government agency dated within the last six (6) months

Record requested

• Name: (as listed on birth certificate) First, Middle, Last
• Date of Birth: (mm / dd / yyyy)
• Town, city or village where birth occurred:
• Name of hospital where birth occurred: (If known)
• Maiden Name of Mother: (as listed on birth certificate) First, Middle, Maiden Last
• Local Registration No.: (If known)
• Father: (as listed on birth certificate) First, Middle, Last
• Number of Copies Requested:

Purpose for which Record is Required: (Check one)

• Passport
• Social Security
• Retirement
• Employment
• Working Papers
• School entrance
• Driver license
• Marriage license
• Welfare assistance
• Veteran's benefits
• Court proceeding
• Entrance into Armed Forces
• Other (specify)

If request is not from child/parents named on the requested certificate, notarized authorization is required.

Applicant

• What is your relationship to person whose record is required? (If self, state "SELF".)
• If attorney, give name and relationship of your client to person whose record is required:
• Signature of Applicant:
• Date Signed: Month, Day, Year
• Address of Applicant: (Applicant's Name), (Street), (City), (State), (Zip)
• Telephone No.:

FOR REGISTRAR'S USE ONLY

(Photocopy ID and attach to application form)

• Type of ID: Driver License - Issuing state, Expiration date, Number
• Other ID, Specify - Number, Type, Number, Type

DOH-296A (06/2005)