"Noncertified Birth Record Application Form" - Minnesota

The Minnesota Department of Health has released this version of the "Noncertified Birth Record Application Form" on October 1, 2018.

This form may be used by all Minnesota residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Noncertified Birth Record Application Form" - Minnesota

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Noncertified Birth Record Application
Fill out this form to obtain a noncertified birth record printed on
plain paper. Noncertified records are for informational use only.
Information to locate the birth record
Child/subject first name
Child/subject middle name
Child/subject last name
Name suffix
City of birth
County of birth
Date of birth
(MM/DD/YYYY)
☐ Female
☐ Male
Parent one first name
Parent one middle name
Parent one last name
Last name before 1st marriage
Name suffix
Parent two first name
Parent two middle name
Parent two last name
Name suffix
Last name before 1st marriage
Requester information – information about you
Requester name
Requester mailing address – street
Apt/Unit #
Daytime phone (xxx-xxx-xxxx)
(UPS will not deliver to PO boxes or APO addresses)
City
State
ZIP
Email
Mandatory - Read the four choices below. Select one of the boxes.
1. ☐ I want an image of the paper record for a birth in 2000 or before. If the record is “confidential”, see number
three below. Only individuals listed in number three below may obtain confidential birth records.
2. ☐ I want a copy of a “public” birth record that includes the subject’s name, date and place of birth, and the names of
the subject’s parents. Health information is not included. Your signature does NOT need to be notarized. Go to
page two of this form.
3.
I want a copy of a “confidential” birth record. A birth record is “confidential” when a child is born to unmarried
parents and the mother does not opt to make the record “public” at the time of birth. Confidential birth records
are available only to those in the following list. Mark one of the boxes below. You must sign this application in
front of a notary. Go to Signature and Notary Information below.
☐ I am the subject of the record age 16 or older
☐ I represent Minnesota programs that administer child support,
medical assistance, MinnesotaCare, and services under Minnesota
☐ I am a parent named on the record
Statutes, sections 124D.23 and 626.556. (Employee ID is required)
☐ I am the guardian of the subject (a certified copy
☐ I am presenting your office with a certified copy of a court order issued
of a court order naming you is required)
by a U.S. court
4. ☐ I want a copy of the entire birth record including health information (available only for births 2001 to present).
☐ I am the mother named on the birth record
Mark a box to the right
☐ I am a representative of local public health
You must sign this application in front of a notary. Go to Signature and Notary Information below.
Signature and Notary Information
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
If I am not eligible to receive the certificate I requested, the Minnesota Department of Health (MDH) will contact me. I give
MDH permission to apply my payment to a follow up application.
Requester signature
Notary stamp/seal
Signed or attested before me on:__
day of____________________, 20 ________
Notary public signature
My commission expires:
PENALTIES: Any person, who willingly and knowingly, without authority, and with intent to deceive, obtains a vital record, is guilty of a
gross misdemeanor (Minnesota Statutes, section 144.227).
Page 1 of 2
OFFICE OF VITAL RECORDS
10/2018
Noncertified Birth Record Application
Fill out this form to obtain a noncertified birth record printed on
plain paper. Noncertified records are for informational use only.
Information to locate the birth record
Child/subject first name
Child/subject middle name
Child/subject last name
Name suffix
City of birth
County of birth
Date of birth
(MM/DD/YYYY)
☐ Female
☐ Male
Parent one first name
Parent one middle name
Parent one last name
Last name before 1st marriage
Name suffix
Parent two first name
Parent two middle name
Parent two last name
Name suffix
Last name before 1st marriage
Requester information – information about you
Requester name
Requester mailing address – street
Apt/Unit #
Daytime phone (xxx-xxx-xxxx)
(UPS will not deliver to PO boxes or APO addresses)
City
State
ZIP
Email
Mandatory - Read the four choices below. Select one of the boxes.
1. ☐ I want an image of the paper record for a birth in 2000 or before. If the record is “confidential”, see number
three below. Only individuals listed in number three below may obtain confidential birth records.
2. ☐ I want a copy of a “public” birth record that includes the subject’s name, date and place of birth, and the names of
the subject’s parents. Health information is not included. Your signature does NOT need to be notarized. Go to
page two of this form.
3.
I want a copy of a “confidential” birth record. A birth record is “confidential” when a child is born to unmarried
parents and the mother does not opt to make the record “public” at the time of birth. Confidential birth records
are available only to those in the following list. Mark one of the boxes below. You must sign this application in
front of a notary. Go to Signature and Notary Information below.
☐ I am the subject of the record age 16 or older
☐ I represent Minnesota programs that administer child support,
medical assistance, MinnesotaCare, and services under Minnesota
☐ I am a parent named on the record
Statutes, sections 124D.23 and 626.556. (Employee ID is required)
☐ I am the guardian of the subject (a certified copy
☐ I am presenting your office with a certified copy of a court order issued
of a court order naming you is required)
by a U.S. court
4. ☐ I want a copy of the entire birth record including health information (available only for births 2001 to present).
☐ I am the mother named on the birth record
Mark a box to the right
☐ I am a representative of local public health
You must sign this application in front of a notary. Go to Signature and Notary Information below.
Signature and Notary Information
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
If I am not eligible to receive the certificate I requested, the Minnesota Department of Health (MDH) will contact me. I give
MDH permission to apply my payment to a follow up application.
Requester signature
Notary stamp/seal
Signed or attested before me on:__
day of____________________, 20 ________
Notary public signature
My commission expires:
PENALTIES: Any person, who willingly and knowingly, without authority, and with intent to deceive, obtains a vital record, is guilty of a
gross misdemeanor (Minnesota Statutes, section 144.227).
Page 1 of 2
OFFICE OF VITAL RECORDS
10/2018
Noncertified Birth Record Application
Fill out this form to obtain a noncertified birth record printed on plain
paper. Noncertified records are for informational use only.
Requester name:
Document requested
Request
Fee
Subtotals
One noncertified birth record
1
$13
$13
How many extra copies do you want?
# extra copies
Fee
Extra copies cost $6 each if you buy them at the same time as one purchased at $13.
X $6 each
$ 0
How do you want your request processed?
Fee
Choose processing
$0
Standard – request processed in the order received
$ 0
Faster – your request goes ahead of standard requests (Does not include UPS delivery)
$20
How do you want your document(s) delivered?
Fee
Choose delivery
$0
Regular First Class Mail®
$ 0
$16
United Parcel Service (UPS)
For UPS delivery, check here ☐ to require a signature.
The Office of Vital Records and UPS are not responsible for deliveries that do not require a signature.
UPS will not deliver to PO boxes or APO addresses.
NOTICE: Fees are payable at the time of application and are non-refundable.
Total amount due:
$ 13
Minnesota Statutes, section 144.226.
Amount must be at least $13
How do you want to pay?
Write in total if filling out by hand
Cardholder name
Valid thru MM/YY
☐ Credit card
Card number
3-digit security code
MasterCard/VISA/Discover
Make check or money order payable to the Minnesota
☐ Check
Department of Health and send by mail with the application.
Check #___________________
Do not send cash.
☐ Money order
Checks returned for non-payment will result in a $30 charge to you. You could
Money order #_________________________
also face civil penalties. Minnesota Statutes, section 604.113, subdivision 2.
If you have questions, contact the Office of Vital Records at
health.vitalrecords@state.mn.us
or call 651-201-5970.
Send application and payment to the Office of Vital Records OR a County Vital Records Office:
Office of Vital Records
County Vital Records Offices Contact Information
(http://www.health.state.mn.us/divs/chs/osr/registrars.html)
Mail application and check or money order
(do not send cash) to:
Minnesota Department of Health
Central Cashiering – Vital Records
PO Box 64499
If you submit this application to a county vital records office, rush delivery may not
St. Paul MN 55164-0499
be an option. Not all forms of payment may be accepted. Call the county vital
records office before submitting your application to confirm payment and delivery
FAX application and credit card information
options.
to: 651-201-5740
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OFFICE OF VITAL RECORDS
10/2018
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