Form HC 1240 Birth Certificate Application - County of Hennepin, Minnesota

Form hc1240 is a Minnesota department of Human services form also known as the "Birth Certificate Application". The latest edition of the form was released in December 1, 2014 and is available for digital filing.

Download an up-to-date fillable Form hc1240 in PDF-format down below or look it up on the Minnesota department of Human services Forms website.

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COUNTY OF HENNEPIN
0
0
DCN/Cert. # ________________
# of Copies: _____ Amount: $ _______
STATE OF MINNESOTA
ID Type
Initials & Emp #___________________
ID #
Issue Date: _______________________
BIRTH CERTIFICATE APPLICATION
NAME OF CHILD:
First
Middle
Last (name on birth record)
 Female
DATE OF
SEX OF
PLACE OF
 Male
BIRTH
MM/DD/YYYY
CHILD
BIRTH
City and County
PARENT’S NAME:
First
Middle
Maiden Name/Birth Name
PARENT’S NAME:
First
Middle
Maiden Name/ Birth Name
Make checks payable to: HENNEPIN COUNTY TREASURER:
Quantity and cost -
$26 first certified copy
$19 each additional copy of the same record issued at the same time as the first copy
$13 uncertified copy (applicant’s signature does NOT need to be notarized)
Please select only one:
I am the subject
I am the child of subject
I am the spouse of subject
I am the parent listed on the record
I am the grandparent of the subject
I am the grandchild of subject
I am the party responsible for filing the birth record.
I am the legal custodian, guardian or conservator of the subject. (must submit certified copy of court order showing relationship)
I am the health care agent of the subject (you must include the health care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate.
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased.
I have documentation that the record is necessary for the determination or protection of personal or property rights. (you must
submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search. (you must submit a
copy of your employee ID)
I am an attorney and I have attached proof of my licensure.
I am presenting your office with a court order issued by a court of competent jurisdiction. (must be a CERTIFIED copy)
I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform its
authorized duties. (you must submit a copy of your employee ID)
I am a representative authorized by a person listed above. (must enclose a notarized statement from a person listed above.)
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a fine of up to $3,000
or both. (MN Statutes section 144.227 and section 609.02, subdivision 3 and 4)
THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION
YOUR NAME:
DATE OF BIRTH:
MM/DD/YYYY
ADDRESS:
City
State
Zip
The information requested on this application is required by MN Statutes, Section 144.225, Subdivision 7 and MN Rules, Part 4601.2600. I certify that the information
provided on this application is accurate and complete to the best of my knowledge.
Reset Form
Print
SIGNATURE:
DATE:
PHONE:
SUBMIT REQUESTS BY MAIL OR FAX TO:
Signature must be notarized (except for uncertified)
if applying by mail or fax
VITAL RECORDS
Hennepin County Government Center
Subscribed and sworn before me this ____day of_______, 20___
300 South 6th St, Suite A025
Minneapolis MN 55487-0026
____________________________________________________
Fax # 612-348-2010
Notary
My Commission expires:
(seal)
HC1240 (12/14)
COUNTY OF HENNEPIN
0
0
DCN/Cert. # ________________
# of Copies: _____ Amount: $ _______
STATE OF MINNESOTA
ID Type
Initials & Emp #___________________
ID #
Issue Date: _______________________
BIRTH CERTIFICATE APPLICATION
NAME OF CHILD:
First
Middle
Last (name on birth record)
 Female
DATE OF
SEX OF
PLACE OF
 Male
BIRTH
MM/DD/YYYY
CHILD
BIRTH
City and County
PARENT’S NAME:
First
Middle
Maiden Name/Birth Name
PARENT’S NAME:
First
Middle
Maiden Name/ Birth Name
Make checks payable to: HENNEPIN COUNTY TREASURER:
Quantity and cost -
$26 first certified copy
$19 each additional copy of the same record issued at the same time as the first copy
$13 uncertified copy (applicant’s signature does NOT need to be notarized)
Please select only one:
I am the subject
I am the child of subject
I am the spouse of subject
I am the parent listed on the record
I am the grandparent of the subject
I am the grandchild of subject
I am the party responsible for filing the birth record.
I am the legal custodian, guardian or conservator of the subject. (must submit certified copy of court order showing relationship)
I am the health care agent of the subject (you must include the health care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate.
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased.
I have documentation that the record is necessary for the determination or protection of personal or property rights. (you must
submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search. (you must submit a
copy of your employee ID)
I am an attorney and I have attached proof of my licensure.
I am presenting your office with a court order issued by a court of competent jurisdiction. (must be a CERTIFIED copy)
I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform its
authorized duties. (you must submit a copy of your employee ID)
I am a representative authorized by a person listed above. (must enclose a notarized statement from a person listed above.)
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a fine of up to $3,000
or both. (MN Statutes section 144.227 and section 609.02, subdivision 3 and 4)
THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION
YOUR NAME:
DATE OF BIRTH:
MM/DD/YYYY
ADDRESS:
City
State
Zip
The information requested on this application is required by MN Statutes, Section 144.225, Subdivision 7 and MN Rules, Part 4601.2600. I certify that the information
provided on this application is accurate and complete to the best of my knowledge.
Reset Form
Print
SIGNATURE:
DATE:
PHONE:
SUBMIT REQUESTS BY MAIL OR FAX TO:
Signature must be notarized (except for uncertified)
if applying by mail or fax
VITAL RECORDS
Hennepin County Government Center
Subscribed and sworn before me this ____day of_______, 20___
300 South 6th St, Suite A025
Minneapolis MN 55487-0026
____________________________________________________
Fax # 612-348-2010
Notary
My Commission expires:
(seal)
HC1240 (12/14)
Affidavit of Identity to Obtain Certified
Birth Certificate
(In order to use this form the identifier must have known applicant for at least 2 years. MN rules 4601.2600 sub 6)
"This page only needs to be completed if the applicant's signature is not notarized on the first page."
Identifier Information
NAME:
First
Middle
Last
ADDRESS:
City
State
Zip
Phone Number
:
DATE OF BIRTH:
DD/MM/YYYY
Relationship
to the Applicant:
I have known
, the Applicant, for
years and solemnly
swear or affirm that he/she is the person presenting this Application for a Certified Birth Certificate.
Print
Reset Form
SIGNATURE:
DATE:
(Sign in the presence of the registrar and present an acceptable document of identity)
When requesting a certified or uncertified copy, or to view/verify information of a birth, death, or marriage record, specific information is
required and is defined as the correct date of the event and the correct name of the registrant.
(Minn. Stat. §
144.226)
Lacking specific
information incurs a “search time” fee of $20 per hour ($10 minimum) in addition to the cost of the copy.
If the Identifier cannot accompany the Applicant to the registrar’s office, the Identifier’s signature MUST
be notarized.
Subscribed and sworn before me this ____day of_______, 20___
(seal)
____________________________________________________
Notary
My Commission expires:_______________________________
Administrative use only:
ID viewed – Type
No.
Init.
HC1240 (12/14)

Download Form HC 1240 Birth Certificate Application - County of Hennepin, Minnesota

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