Form A Birth Certificate Application - Washington, D.C.

Form A is a Washington DC Department of Health form also known as the "Birth Certificate Application". The latest edition of the form was released in June 2, 2015 and is available for digital filing.

Download a fillable PDF version of the Form A down below or find it on Washington DC Department of Health Forms website.

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District of Columbia
Birth Certificate Application
Please follow the instructions below when submitting your application.
Please note: THE D.C. REGISTRAR MAY, AT ANY TIME, REQUEST ADDITIONAL DOCUMENTATION TO
HELP DETERMINE THE IDENTITY OR ELIGIBILITY OF THE APPLICANT.
1. A separate application form must be submitted for each individual certificate being requested, and a separate VitalChek
Processing Fee is required for each separate application.
("LexisNexis VitalChek Network Inc. is in partnership with the District of Columbia Dept. of Health to enable enhanced electronic processing of mail-in vital record applications.")
2. Current identification (as listed on the table below) is required for each certificate being requested. Expired IDs will not
be accepted.
Choose 1 Primary ID, OR at least 3 Secondary IDs (if Primary ID is not available)
Valid, unexpired State-issued
Valid, unexpired State-issued ID Card
PRIMARY ID (1)
Valid, unexpired Passport
driver’s license
(non-driver)
OR
W-2 Form or current, filed tax form
Current utility bill showing full name and address
SECONDARY ID
Current pay stub
School ID with transcript
(3 or more)
Work ID with photo
Veteran ID
Social Security Card with signature
Notarized letter from parent listed on certificate
Valid Department of Corrections ID Card with photo,
Voter Registration Card
accompanied by probation documents or discharge papers
Court Order
Car registration or title with current name and address
Military ID or Selective Service Card
Federal Government Census Record
3. Only the persons named on the certificate (Parents or Child), an immediate family member or a legal
representative are eligible to receive DC birth certificates. If you are not one of the persons named on the birth
certificate, you must also send additional documentation (as shown below) with your completed application to prove
your relationship to the person named on the certificate or your legal need to the certificate.
Relationship to Person
Additional Documentation Required
Named on Certificate
(in addition to the required identification listed above)
Sibling or Adult Child
A copy of your birth certificate
Grandparent
A copy of your child’s birth certificate
A copy of your birth certificate, and a copy of your parent’s birth certificate which names
Adult Grandchild
your grandparent
Legal Guardian
A copy of the valid guardianship papers certified by the court naming you as legal guardian
A copy of your work ID, and
A letter from the parent (or legal guardian), a court order, or a letter from your
Social Worker
organization (on official letterhead, signed by a supervisor) stating your professional
relationship to the person named on the certificate being requested
A signed document stating you have been retained by your client (such as a retainment or
engagement letter), documentation establishing a legal or tangible interest in the record
Attorney
(such as court paperwork), or a letter (on official letterhead) stating your professional
relationship to the person named on the certificate being requested
Other
Documentation providing legal, tangible interest in the certificate being requested
4. If the record you requested is not located, a “Certificate of Search” will be issued. As the request was processed and
the certificate was searched for, both the Agency Certificate Fee and the VitalChek Processing Fee are non-refundable.
5. Please mail your completed application, along with identification and additional documentation (if required), to:
Department of Health
For expedited order placement
Vital Records Division
ATTN: New Applications Dept.
and processing please visit
st
899 North Capitol St., NE, 1
Floor
www.VitalChek.com.
Washington, DC 20002
6. Please allow 5 -7 business days for your application to be received prior to calling our customer service department with
any questions about your application. We can be reached at 1-877-572-6332.
District of Columbia
Birth Certificate Application
Please follow the instructions below when submitting your application.
Please note: THE D.C. REGISTRAR MAY, AT ANY TIME, REQUEST ADDITIONAL DOCUMENTATION TO
HELP DETERMINE THE IDENTITY OR ELIGIBILITY OF THE APPLICANT.
1. A separate application form must be submitted for each individual certificate being requested, and a separate VitalChek
Processing Fee is required for each separate application.
("LexisNexis VitalChek Network Inc. is in partnership with the District of Columbia Dept. of Health to enable enhanced electronic processing of mail-in vital record applications.")
2. Current identification (as listed on the table below) is required for each certificate being requested. Expired IDs will not
be accepted.
Choose 1 Primary ID, OR at least 3 Secondary IDs (if Primary ID is not available)
Valid, unexpired State-issued
Valid, unexpired State-issued ID Card
PRIMARY ID (1)
Valid, unexpired Passport
driver’s license
(non-driver)
OR
W-2 Form or current, filed tax form
Current utility bill showing full name and address
SECONDARY ID
Current pay stub
School ID with transcript
(3 or more)
Work ID with photo
Veteran ID
Social Security Card with signature
Notarized letter from parent listed on certificate
Valid Department of Corrections ID Card with photo,
Voter Registration Card
accompanied by probation documents or discharge papers
Court Order
Car registration or title with current name and address
Military ID or Selective Service Card
Federal Government Census Record
3. Only the persons named on the certificate (Parents or Child), an immediate family member or a legal
representative are eligible to receive DC birth certificates. If you are not one of the persons named on the birth
certificate, you must also send additional documentation (as shown below) with your completed application to prove
your relationship to the person named on the certificate or your legal need to the certificate.
Relationship to Person
Additional Documentation Required
Named on Certificate
(in addition to the required identification listed above)
Sibling or Adult Child
A copy of your birth certificate
Grandparent
A copy of your child’s birth certificate
A copy of your birth certificate, and a copy of your parent’s birth certificate which names
Adult Grandchild
your grandparent
Legal Guardian
A copy of the valid guardianship papers certified by the court naming you as legal guardian
A copy of your work ID, and
A letter from the parent (or legal guardian), a court order, or a letter from your
Social Worker
organization (on official letterhead, signed by a supervisor) stating your professional
relationship to the person named on the certificate being requested
A signed document stating you have been retained by your client (such as a retainment or
engagement letter), documentation establishing a legal or tangible interest in the record
Attorney
(such as court paperwork), or a letter (on official letterhead) stating your professional
relationship to the person named on the certificate being requested
Other
Documentation providing legal, tangible interest in the certificate being requested
4. If the record you requested is not located, a “Certificate of Search” will be issued. As the request was processed and
the certificate was searched for, both the Agency Certificate Fee and the VitalChek Processing Fee are non-refundable.
5. Please mail your completed application, along with identification and additional documentation (if required), to:
Department of Health
For expedited order placement
Vital Records Division
ATTN: New Applications Dept.
and processing please visit
st
899 North Capitol St., NE, 1
Floor
www.VitalChek.com.
Washington, DC 20002
6. Please allow 5 -7 business days for your application to be received prior to calling our customer service department with
any questions about your application. We can be reached at 1-877-572-6332.
FOR VITALCH EK USE ONLY
District of Columbia
Birth Certificate Application
Order # __________________
Restriction on Access to Birth Certificates: Pursuant to D.C. Official Code Sec. 7-220, the Vital Records Division may issue a certified
copy of a birth certificate ONLY to an applicant having a direct and tangible interest in the requested birth certificate.
NOTE: This form should be used ONLY by a person named on the certificate, an immediate family member, guardian or legal representative.
STEP 1: CERTIFICATE INFORMATION
Full Name of Child at Time of Birth (Certificate Holder)
first name
middle name
last name
suffix
Father’s / Parent's Full Name
first name
middle name
last name (maiden name if applicable)
suffix (if applicable)
Mother’s / Parent's Full Name
first name
middle name
last name (maiden name if applicable)
suffix (if applicable)
Date of Birth
Hospital
Gender
Still Living
Male
Yes
(MM/DD/YYYY)
Female
No
Reason for Request
STEP 2: YOUR INFORMATION AND SHIPPING ADDRESS
Your Full Name (Applicant)
first name
middle name
last name
suffix
Your Street Address
City
State
Zip Code
Your Relationship to Person Named on Certificate
E-mail Address
Daytime Phone Number
(for communication & status updates)
Name and Address to Send Certificate (if different than noted above)
first name
middle name
last name
suffix
Ship To Address
City
State
Zip Code
Your Signature (Applicant)
Date of Application
STEP 3: COST
STEP 4: PAYMENT INFORMATION
Qty
Price/ea
Total
Select Payment Method:
Submit separate payment for each Application
NUMBER OF COPIES:
Credit Card
Personal Check
Money Order
First copy
1
$23.00
$23.00
DO NOT SEND CASH
Additional copies (up to 4)
x $23.00
TOTAL FOR ALL COPIES ABOVE
Credit Card Information:
(if paying by Credit Card)
$
SELECT DELIVERY METHOD (choose one):
UPS will not deliver to a P.O. Box
Credit Card Number
Expiration Date
Processing time may take 7-10 business days
UPS Next Day Air
$20.00
Cardholder’s Signature
Date
UPS Alaska, Hawaii, Puerto Rico
$40.00
Charges will appear on your Credit Card statement as: VCN DC VITAL RECORDS
UPS to Canada or Mexico
$26.00
If paying by check or money order, make payable to VITALCHEK.
UPS Worldwide Expedited
$36.50
U.S. Postal Service Regular Mail
$0.00
STEP :
B
TOTAL FOR SELECTED DELIVERY
$
Please mail your completed form, along with ID and additional documentation
(if required) to:
TOTAL FOR VITALCHEK PROCESSING AND
Department of Health, Vital Records Division
HANDLING FEE
(non-refundable)
$
6.00
ATTN: New Applications Dept.
st
899 North Capitol St., NE, 1
Floor
A + B + C
TOTAL AMOUNT DUE =
$
Washington, DC 20002
06022015-A
For expedited order placement and processing please visit www.VitalChek.com.

Download Form A Birth Certificate Application - Washington, D.C.

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