Birth Certificate Request Form - City Of Ashtabula Health Department
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Birth Certificate Request Form
City of Ashtabula Health Department
Name at Birth:
Date of Birth:
Mother’s Maiden Name:
Father’s Name:
Person Making Request:
Requestor’s Address:
City:
State:
Zip:
Contact Phone:
Requestor’s Signature:
Print this form, sign it and mail along with a check for $25.00 and a self- addressed stamped envelope to:
Ashtabula City Health Department
4717 Main Avenue
Ashtabula, Ohio 44004
OR
We accept Visa & Mastercard & Discover. There is a $3.00 convenience fee for use of credit card.
You may call in your credit card information to (440) 992-7123 or print this form, sign it and fax it to
440-992-7163 along with a copy of your credit card (front & back) and fill out the information below:
Visa
Mastercard
Discover
Name on Card:
Account #:
Exp Date:
Billing Phone:
3 Digit V Code on Back of Card:
Billing Address:
City:
State:
Zip:
Cardholder Signature:
* By signing this you are authorizing the City of Ashtabula to debit your account for the charges due.
You will be charged $25 for the certified copy, $3.00 convenience fee on use of credit card and postage.
Please check the type of postage you prefer:
Regular Mail $0.49*
Priority Mail $5.60*
Express Mail $19.99*
*These fees are charged according to what the USPS is charging at the time of the order.
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