Birth Certificate Request Form
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Birth Certificate Request
Birth Certificate Request
Birth Certificate Request
Division of Vital Records
th
Phone:
1000 NE 10
1000 NE 10
Street
PO Box 53551
Walk-in Hours:
(405) 271-4040
Oklahoma City, OK 73117
Oklahoma City, OK 73117
Oklahoma City, OK 73152
Mon-Fri 8:30-4:00
Full Name AT BIRTH:
Male
Female
(If a change to the name has occurred, please see instruction on back)
(If a change to the name has occurred, please see instruction on back)
____________________
____________________
____________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
If Child less than 2 yrs:
First
Middle
Middle
Last
__________________
Date of Birth: _____ / ______ / _____
Place of Birth:
Place of Birth: _____________________ , OKLAHOMA
, OKLAHOMA
Name of Hospital or Midwife
Month
Month
Day
Day
Year
Year
City and/or County
City and/or County
Full Name of Father: ____________________
________
________________________
________________________ _______________________
_______________________
First
First
Middle
Last
Full MAIDEN Name of Mother: _________________
_________________
________________
________________
________________________________
________________________________
First
First
Middle
Middle
Last Name
Last Name prior to first marriage
This request is being made by:
Person Himself/Herself
Parent
Legal Guardian or Custodian
Legal Guardian or Custodian
Authorized Agent, must specify: __________________________________
__________________________________
Current Address (REQUIRED):
Name _________________________________________________________
Name ___________________________________________________________
__
Daytime Telephone Number: (________) _______ - ________________
Daytime Telephone Number: (________) _______
Mailing Address _______________________________________________Apt _______
Mailing Address _______________________________________________Apt _______
City, State and Zip ______________________________
State and Zip ______________________________
E-mail Address_______________________________________________________________
mail Address_______________________________________________________________
No email
Purpose for which the birth certificate is needed:
Purpose for which the birth certificate is needed:
Drivers License
Social Security
Passport
School
State Assistance Pgm
Other, specify: _______________________________
_______________________________
By signing below, I declare that all information provided on this request is true and cor
By signing below, I declare that all information provided on this request is true and cor
By signing below, I declare that all information provided on this request is true and correct.
Signature: __________________________________________________________
Signature: __________________________________________________________
Signature: __________________________________________________________
Date Signed: ________________________________
Date Signed: ________________________________
Date Signed: _________________________________
(Request will not be processed without the signature of the requestor and established eligibility.)
(Request will not be processed without the signature of the requestor and established eligibility.)
Fees
A fee is to be paid for a search of the files or records, even when no copy is available. Search fees are non
paid for a search of the files or records, even when no copy is available. Search fees are non-transferable and non
transferable and non-refundable.
_______ Number of certified copies requested ($15 each and includes search fee)
_______ Number of certified copies requested ($15 each and includes search fee)
_______ Delayed registration, amendment, paternity, adoption, or legitimation fee ($40
registration, amendment, paternity, adoption, or legitimation fee ($40 - Includes one certified copy)
Includes one certified copy)
_______ Number of Heirloom certificates requested: ($35 each and includes one certified copy)
_______ Number of Heirloom certificates requested: ($35 each and includes one certified copy)
_______ Total Amount enclosed
Make checks payable to OSDH. Do not send cash by mail.
ble to OSDH. Do not send cash by mail.
FEES: A record search is $15 and includes the issuance of one certified copy if the record is found; additional copies are $15 each
A record search is $15 and includes the issuance of one certified copy if the record is found; additional copies are $15 each
A record search is $15 and includes the issuance of one certified copy if the record is found; additional copies are $15 each. If no record is found; the
fee will not be refunded. The fee to amend a record is $40 ($25 processing fee + $15 for one certified copy). Should you receive a request for mo
nded. The fee to amend a record is $40 ($25 processing fee + $15 for one certified copy). Should you receive a request for mo
nded. The fee to amend a record is $40 ($25 processing fee + $15 for one certified copy). Should you receive a request for more information,
please respond promptly as all fees and files will expire one year after the date paid.
please respond promptly as all fees and files will expire one year after the date paid.
Requirements:
1) This request must
must be completed in full.
2) Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)
Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)
Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)
3) Enclose appropriate fees
Enclose appropriate fees
4) Person requesting to receive a birth certificate must sign
Person requesting to receive a birth certificate must sign above
above
5) If submitting by mail, enclose a self
If submitting by mail, enclose a self-addressed stamped envelope
addressed stamped envelope
OFFICE USE ONLY
Mail
Front Desk
Front Desk
Reviewed by: ____________________ Date: ______ / _____ / ______
Reviewed by: ____________________ Date: ______ / _____ / ______
Clerk: ______________ Date: ________ / _______ / ________
Clerk: ______________ Date: ________ / _______ / ________
Fees Enclosed: $_________________ Fees Due: $ _______________
_______________ Fees Due: $ _______________
Fees Paid: $ _______________
Check
Cash
MO
CC
ID Enclosed: _____________________
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