1
2COUNTY 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)
