"Request for a Certified Copy of a Birth Record From the Town" - Connecticut

Request for a Certified Copy of a Birth Record From the Town is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on May 1, 2012;
  • The latest edition currently provided by the Connecticut State Department of Public 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 printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Request for a Certified Copy of a Birth Record From the Town" - Connecticut

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REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE TOWN
Mail this request to the Town Vital Records office. For the address and phone number of Town Vital
Records offices in Connecticut, please refer to the Town website or the DPH website at www.ct.gov/dph.
PLEASE PRINT
FULL NAME ON CERTIFICATE*:________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
DATE OF BIRTH: ________/________/________
PLACE OF BIRTH: _____________________________________________
MONTH
DAY
YEAR
TOWN/CITY
FATHER’S FULL NAME: ________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
PERSON MAKING THIS REQUEST:
NAME: ________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: _____________________________________________________________________________________________________
NUMBER/STREET/UNIT #
TOWN/CITY: __________________________________________________ STATE: _____________ ZIP CODE: _____________
TELEPHONE NO: ____________________________________ E-MAIL ADDRESS: ______________________________________
SIGNATURE: X_________________________________________________________________________________________________
RELATION TO PERSON NAMED ON CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: ______________________________________________________________________________
CERTIFICATE SIZE:
TOTAL NUMBER OF COPIES:
FULL SIZE
WALLET SIZE
The wallet size birth certificate contains less
_______ X $20.00 = $ _______
information than the full size certificate. It
does not satisfy the proof of identification
$20.00 EACH
_______ X $15.00 = $ _______
requirements needed for a passport or a
driver’s license.
TOTAL: $ _______
$15.00 EACH
NUMBER OF COPIES: __________
Send Postal Money Order Only. Do
NUMBER OF COPIES: __________
Not Mail Cash or Personal Checks.
Attach a copy of the requester’s valid government issued photo
Please mail the completed request with the following required
ID or passport below:
documents:
Or two (2) forms of the following:
Money order made payable to City/Town (refer to the
Town or DPH website cited above)
-
Social security (SS) card
Current government issued photo ID
-
Paycheck Stub or a W-2 form that contains the SS #
(If applicable) verification of relationship to the registrant
-
Current school or college photo ID
(for example, an individual requesting his/her parent’s
-
Automobile registration
birth certificate must provide a certified copy of his/her
-
Copy of utility bill or bank statement showing name and
own birth certificate).
address
-
See website ct.gov\dph for other forms of ID accepted
*If adopted, please provide your adoptive name and adoptive parents’ information.
Birth Request form from Town Rev. 5-2012
*If the requester had a legal name change, please provide a copy of the court documents authorizing the name change.
REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE TOWN
Mail this request to the Town Vital Records office. For the address and phone number of Town Vital
Records offices in Connecticut, please refer to the Town website or the DPH website at www.ct.gov/dph.
PLEASE PRINT
FULL NAME ON CERTIFICATE*:________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
DATE OF BIRTH: ________/________/________
PLACE OF BIRTH: _____________________________________________
MONTH
DAY
YEAR
TOWN/CITY
FATHER’S FULL NAME: ________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
PERSON MAKING THIS REQUEST:
NAME: ________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: _____________________________________________________________________________________________________
NUMBER/STREET/UNIT #
TOWN/CITY: __________________________________________________ STATE: _____________ ZIP CODE: _____________
TELEPHONE NO: ____________________________________ E-MAIL ADDRESS: ______________________________________
SIGNATURE: X_________________________________________________________________________________________________
RELATION TO PERSON NAMED ON CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: ______________________________________________________________________________
CERTIFICATE SIZE:
TOTAL NUMBER OF COPIES:
FULL SIZE
WALLET SIZE
The wallet size birth certificate contains less
_______ X $20.00 = $ _______
information than the full size certificate. It
does not satisfy the proof of identification
$20.00 EACH
_______ X $15.00 = $ _______
requirements needed for a passport or a
driver’s license.
TOTAL: $ _______
$15.00 EACH
NUMBER OF COPIES: __________
Send Postal Money Order Only. Do
NUMBER OF COPIES: __________
Not Mail Cash or Personal Checks.
Attach a copy of the requester’s valid government issued photo
Please mail the completed request with the following required
ID or passport below:
documents:
Or two (2) forms of the following:
Money order made payable to City/Town (refer to the
Town or DPH website cited above)
-
Social security (SS) card
Current government issued photo ID
-
Paycheck Stub or a W-2 form that contains the SS #
(If applicable) verification of relationship to the registrant
-
Current school or college photo ID
(for example, an individual requesting his/her parent’s
-
Automobile registration
birth certificate must provide a certified copy of his/her
-
Copy of utility bill or bank statement showing name and
own birth certificate).
address
-
See website ct.gov\dph for other forms of ID accepted
*If adopted, please provide your adoptive name and adoptive parents’ information.
Birth Request form from Town Rev. 5-2012
*If the requester had a legal name change, please provide a copy of the court documents authorizing the name change.