Form H105.102 - Application For Certified Copy Of Birth Record printable pdf download

Application for Certified Copy of Birth Record

H105.102 REV 05/2015

BIRTH

Pennsylvania Department of Health ♦ Division of Vital Records

PART 1:

By my signature below, I state I am the person whom I represent myself to be herein, and I affirm the information within this form

is complete and accurate and made subject to the penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. In addition, I

acknowledge that misstating my identity or assuming the identity of another person may subject me to misdemeanor or felony criminal

penalties for identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the Pennsylvania Crimes Code. (Note: Signature must agree with

name listed in Parts 2 and 5 of this form.)

Signature of person making request (Do not print): __________________________________________________________________________

Signature required on ALL requests. Must be 18 years of age or older to apply. If under 18, immediate family member must request record.

PART 2:

PRINT or TYPE name of individual requesting record and his/her current mailing address.

Relationship to Person

Name: ___________________________________________________ Named on Record: ______________________________________

Address:________________________________________________________________________________________________________

City:__________________________________________________________________ State: __________________ Zip:__________

Daytime phone number: (______) _______ - _________

E-mail Address:________________________________________

□

Intended Use of Certified Copy:

Travel/Passport

Social Security/Benefits

School

Employment

□

Driver’s License

Other (List reason: _________________________________________________________)

PART 3:

PRINT or TYPE information below regarding person named on requested record:

Number of copies: ________

Name at Birth: __________________________________________________________________________________________________

If name has changed since birth due to adoption, court order,

or any reason

marriage, please list that name here: _____________________________________________________________

other than

□

Date of Birth:________________________________________________ Age Now: __________

Sex:

Male

Female

(Month/Day/Year - Records available from 1906 to the present)

Place of Birth: ___________________________________________________________________ Hospital: _______________________

(County)

(City/Boro/Twp. In Pennsylvania)

Mother’s or Parent A’s Name: _______________________________________________________________________________________

(First)

(Middle)

(Last prior to marriage)

(Current last)

Father’s or Parent B’s Name: _________________________________________________________________________________________

(First)

(Middle)

(Last prior to marriage)

(Current last)

PART 4:

BIRTH: $20.00 each.

If fee is required, make check/money order payable to: VITAL RECORDS.

Fees may be waived for individuals and their dependents who served or are currently serving in the Armed Forces (complete the following):

Armed Forces Member’s Name: ________________________________________Service Number:________________________________

Relationship to Armed Forces Member: _________________________Rank and Branch of Service:________________________________

PART 5:

VALID GOVERNMENT ISSUED PHOTO ID REQUIRED

♦ Individual requesting record must send a legible copy of his/her valid government issued photo ID that verifies name and

mailing address as listed in Part 2 above.

♦ Examples: State issued driver’s license or non-driver photo ID (if address has been changed, include copy of update card).

♦ If possible, enlarge photo ID on copier by at least 150% (copies of ID will be shredded upon review).

♦ If acceptable ID not available, visit our website at

for further information.

Mail to:

Have you?

Division of Vital Records

 Signed your name in Part 1 (do not

ATTN: Birth Unit

print)

PO BOX 1528

 Listed your name and current mailing

NEW CASTLE, PA 16103

address in Parts 2 and 5

 Completed all items in Part 3 (enter

Print or type name and address in the space provided below

unknown if information unavailable)

(Must agree with name and current address in Part 2 and ID documentation):

 Enclosed payment (or completed Part 4

for waiver of fee)

Name

 Enclosed legible copy of ID (must agree

with your name and address in Parts 2

Street

and 5)

City, State, Zip Code

For

EXPEDITED ON-LINE ORDERING

or additional information, visit our website:

Form H105.102 - Application For Certified Copy Of Birth Record

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