"Birth Certificate Application Form" - Minnesota

Birth Certificate Application Form is a legal document that was released by the Minnesota Department of Health - a government authority operating within Minnesota.

Form Details:

  • Released on July 1, 2021;
  • The latest edition currently provided by the Minnesota Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Department of Health.

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Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
You must fill in the information we ask for on this form. We need the information to find the correct birth record
and to make sure that you may receive the certificate. If we cannot find the birth record you asked for, we will
send you a certified “Statement of No Birth Record Found”. Minnesota Rules, part 4601.2600
Section A
Information to find the requested birth record
Minnesota Rules, part 4601.2600, subpart 2
Child/subject first name
Child/subject middle name
Child/subject last name
Name suffix
Sex
Date of birth (MM/DD/YYYY)
Minnesota city of birth
Minnesota county of birth
State of birth
☐ Female
MN
☐ Male
Parent one first name
Parent one middle name
Parent one last name
Last name before 1
st
marriage
Name suffix
Parent two first name
Parent two middle name
Parent two last name
Last name before 1
st
marriage
Name suffix
Section B
Requester - person completing this application
Minnesota Rules, part 4601.2600, subpart 3
Requester full name
Date of birth
Daytime phone (10-digit)
(MM/DD/YYYY)
Requester mailing address – street
Apt/Unit #
Email
(United Parcel Service (UPS) will not deliver to PO boxes or APO addresses.)
City
State
ZIP Code™
Section C
MANDATORY — Check the boxes below that describe your relationship to the subject of the record:
Marital status is important.
Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1 – 18
below. Records of children born to single mothers are “confidential” unless the mother chose to make the record public at the time of
birth. Only the persons listed below in items 19 – 23 may obtain confidential birth certificates.
Minnesota Statutes, section 144.225, subdivisions 2 and 7.
“Public” birth records are available to individuals who meet any of the legal requirements in items 1-18
1. ☐ A parent named on the subject’s record
2. ☐ A grandparent of the subject
3. ☐ A great grandparent of the subject
4. ☐ A child of the subject
5. ☐ A grandchild of the subject
6. ☐ A great-grandchild of the subject
8. ☐ I am the subject; I am requesting my own birth record
7. ☐ Spouse of the subject (You must be the current spouse)
9. ☐ The legal custodian, guardian, or conservator of the subject (we need a certified copy of the court order that names you)
10. ☐ The health care agent for the subject (we need a valid “health care power of attorney” document)
11. ☐ Subject’s personal representative (we need a notarized statement that says you need the birth certificate to administer the estate)
12. ☐ Successor of the subject (subject is dead) (we need a notarized statement that says you need the birth certificate to administer the estate)
13. ☐ Proof that you need a birth certificate for the determination or protection of a personal or property right
14. ☐ Adoption agency — to complete post-adoption search (we need a copy of your Employee ID)
15. ☐ Local/state/tribal or federal governmental agency (we need a copy of your Employee ID) (Best practice: wait for family to verify the record).
16. ☐ Attorney – I represent the subject, or a person listed in items 1-14 above.
If you are a NON-Minnesota attorney, attach a copy
My Minnesota Attorney License Number is:
of your attorney license.
17. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
18. ☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ names, the signer’s
relationship to the subject of the record and it authorizes me to obtain the certificate.
“Confidential” birth records are available only under the conditions, or to the person, in items 19-23
19. ☐ Parent named on the subject’s record
20. ☐ The legal custodian, guardian, or conservator of the subject (you need a certified copy of a court order naming you)
21. ☐ The subject, when 16 years old or older
22. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under
Minnesota Statutes, sections 124D.23; Minnesota Statutes, chapter 260E; and, tribal child support programs, Minnesota
Statutes, section 144.225, subdivision 2, paragraph (f). (we need a copy of your Employee ID)
23. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
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Birth Certificate Application
Complete this form to order a certified copy of a Minnesota birth certificate.
You must fill in the information we ask for on this form. We need the information to find the correct birth record
and to make sure that you may receive the certificate. If we cannot find the birth record you asked for, we will
send you a certified “Statement of No Birth Record Found”. Minnesota Rules, part 4601.2600
Section A
Information to find the requested birth record
Minnesota Rules, part 4601.2600, subpart 2
Child/subject first name
Child/subject middle name
Child/subject last name
Name suffix
Sex
Date of birth (MM/DD/YYYY)
Minnesota city of birth
Minnesota county of birth
State of birth
☐ Female
MN
☐ Male
Parent one first name
Parent one middle name
Parent one last name
Last name before 1
st
marriage
Name suffix
Parent two first name
Parent two middle name
Parent two last name
Last name before 1
st
marriage
Name suffix
Section B
Requester - person completing this application
Minnesota Rules, part 4601.2600, subpart 3
Requester full name
Date of birth
Daytime phone (10-digit)
(MM/DD/YYYY)
Requester mailing address – street
Apt/Unit #
Email
(United Parcel Service (UPS) will not deliver to PO boxes or APO addresses.)
City
State
ZIP Code™
Section C
MANDATORY — Check the boxes below that describe your relationship to the subject of the record:
Marital status is important.
Records of children born to married parents are “public”. That means that the certificate is available to those listed in items 1 – 18
below. Records of children born to single mothers are “confidential” unless the mother chose to make the record public at the time of
birth. Only the persons listed below in items 19 – 23 may obtain confidential birth certificates.
Minnesota Statutes, section 144.225, subdivisions 2 and 7.
“Public” birth records are available to individuals who meet any of the legal requirements in items 1-18
1. ☐ A parent named on the subject’s record
2. ☐ A grandparent of the subject
3. ☐ A great grandparent of the subject
4. ☐ A child of the subject
5. ☐ A grandchild of the subject
6. ☐ A great-grandchild of the subject
8. ☐ I am the subject; I am requesting my own birth record
7. ☐ Spouse of the subject (You must be the current spouse)
9. ☐ The legal custodian, guardian, or conservator of the subject (we need a certified copy of the court order that names you)
10. ☐ The health care agent for the subject (we need a valid “health care power of attorney” document)
11. ☐ Subject’s personal representative (we need a notarized statement that says you need the birth certificate to administer the estate)
12. ☐ Successor of the subject (subject is dead) (we need a notarized statement that says you need the birth certificate to administer the estate)
13. ☐ Proof that you need a birth certificate for the determination or protection of a personal or property right
14. ☐ Adoption agency — to complete post-adoption search (we need a copy of your Employee ID)
15. ☐ Local/state/tribal or federal governmental agency (we need a copy of your Employee ID) (Best practice: wait for family to verify the record).
16. ☐ Attorney – I represent the subject, or a person listed in items 1-14 above.
If you are a NON-Minnesota attorney, attach a copy
My Minnesota Attorney License Number is:
of your attorney license.
17. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
18. ☐ I have a signed statement from a person above; it specifies the subject’s full name, date of birth, parents’ names, the signer’s
relationship to the subject of the record and it authorizes me to obtain the certificate.
“Confidential” birth records are available only under the conditions, or to the person, in items 19-23
19. ☐ Parent named on the subject’s record
20. ☐ The legal custodian, guardian, or conservator of the subject (you need a certified copy of a court order naming you)
21. ☐ The subject, when 16 years old or older
22. ☐ Representatives of Minnesota programs that administer child support, medical assistance, MinnesotaCare, and services under
Minnesota Statutes, sections 124D.23; Minnesota Statutes, chapter 260E; and, tribal child support programs, Minnesota
Statutes, section 144.225, subdivision 2, paragraph (f). (we need a copy of your Employee ID)
23. ☐ Pursuant to a valid, certified copy of a U.S. court order (not a subpoena) releasing the certificate
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B I R T H C E R T I F I C A T E A P P L I C A T I O N
Person completing this application – the requester:
Section D
Requester’s signature and signature of notary public
I certify that the information on this application is correct and complete to the best of my knowledge.
It is unlawful to give false information to get a birth certificate. You may be subject to fines, jail time or both.
Minnesota Statutes, section 144.227.
Requester’s signature (Signature must match the name of the requester on page one)
Notary Stamp/Seal
Signed or attested before me on: ________ day of _____
, 20
Printed name of notary public
Notary public signature
My commission
expires
Section E
How many birth certificates do you want?
Fee
Subtotals
$26
$26
One certified birth certificate
# of added
$19
copies
Added copies are $19 each if you buy them at the same time as one at $26.
each
Section F
How many VA birth certificates do you want?
Minnesota Statutes, section 197.63, subdivision 1
# VA certificates
VA birth certificates are available free - for Veterans Affairs related purposes only
$0
Section G
Do you want standard or faster processing?
Fee
Choose processing
$0
Standard – request processed in the order received
Faster – your request goes ahead of standard requests (Does not include UPS® delivery)
$20
Enter $0 or $20
Fee
Choose delivery
Section H
How do you want us to send your documents back to you?
Regular First-Class Mail®
$0
United Parcel Service (UPS®)
$16
Enter $0 or $16
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. If you want UPS® delivery to an address
outside of the United States, you must include a UPS® prepaid envelope when you mail your application and fees.
The amount you pay must cover the certificates and services you requested
Amount due
Section I
above.
Payment due = subtotals from Sections E, G, and H above
(Must be $26 or more)
Fees are due with the application and are non-refundable. Minnesota Statutes, section
Section J
How do you want to pay?
144.226.
Cardholder name
Valid thru MM/YY
☐ Credit card
MasterCard/VISA/Discover
Card number
3-digit security code
Check #
☐ Check
Make check or money order payable to the Minnesota Department
of Health and send by mail with application. DO NOT SEND CASH.
Money order #
Checks returned for non-payment will result in a $30 charge to you. You
☐ Money order
could also face civil penalties. Minnesota Statutes, section 604.113,
subdivision 2.
Section K
Send your application and payment
Minnesota Department of Health
The Office of Vital Records returns applications that are
By mail
Office of Vital Records
incomplete, not signed in front of a notary public, or not paid in
(Do not send cash)
PO Box 64499
full at the time of application.
St. Paul MN 55164-0499
By FAX
866-416-1357 (Application with credit card information only)
If you have questions, contact
health.vitalrecords@state.mn.us
or call 651-201-5970.
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