- Legal
- United States Legal Forms
- Connecticut Legal Forms
- City Clerk's Office - City of Derby, Connecticut
- "Application Form for Birth Certificate" - City of Derby, Connecticut
"Application Form for Birth Certificate" - City of Derby, Connecticut
Application Form for Birth Certificate is a legal document that was released by the City Clerk's Office - City of Derby, Connecticut - a government authority operating within Connecticut. The form may be used strictly within City of Derby.
Form Details:
- The latest edition currently provided by the City Clerk's Office - City of Derby, Connecticut;
- 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 City Clerk's Office - City of Derby, Connecticut.
Download "Application Form for Birth Certificate" - City of Derby, Connecticut
!["Application Form for Birth Certificate" - City of Derby, Connecticut](https://data.templateroller.com/pdf_docs_html/6/62/6253/page_1_thumb.png ""Application Form for Birth Certificate" - City of Derby, Connecticut")
1CITY OF DERBY
Marc J. Garofalo, Town Clerk
1 Elizabeth Street - Derby, CT 06418
(203)736-1462
APPLICATION FOR BIRTH CERTIFICATE:
All issued Birth Certificates are certified with a raised seal.
Mark box A or B:
Long Form (Exact copy of original) - $20
Type A
(Required for Passport Applications and any institution requiring proof of parents)
Type B
Short Form (Wallet size) - $15
Fee: Cash Only when requested in person. Money order only when requested by mail.
Access to birth records less than 100 years old is restricted in Connecticut.
CURRENT PHOTOGRAPHIC IDENTIFICATION OF REQUESTER IS REQUIRED
(Driver’s License or Passport)
Photographic identification may be substituted by any two of the following documents:
Recent Paystub (showing name and address)
Current Automobile Registration (showing name & address)
Voter Registration card
Social Security Card
Recent copy of Utility bill (showing name & address)
Checking Account Deposit Slip (showing name & address)
I am applying for the Birth Certificate of:
Full Name at Birth: ______________________________________
My own birth certificate
(first, middle, last)
(16 or 17 years of age have access to wallet size only)
Date of Birth: __________________________________________
My child’s birth certificate
(month/day/year)
Place of Birth: __________________________________________
My parent’s birth certificate
(Town/State)
(must provide own long form birth certificate)
Father’s Full Name: ______________________________________
My spouse’s birth certificate
(first/middle/last)
(must provide marriage license)
Mother’s Full Maiden Name: ______________________________
My grandchild’s birth certificate
(first/middle/maiden last)
(must provide own child’s birth certificate)
My grandparents’s birth certificate
(must provide own & parent’s long form birth cert)
My client’s. I am the Attorney or Legal
Guardian
(must provide legal documentation)
Printed Name of Requester: ________________________________
Signature of Requester: ____________________________________
Address of Requester: ____________________________________________________________________________
Phone Number: __________________________________________
When mailing this form, please be sure to include the following items:
Original Application Form, Money Order for the total copies requested made payable to the City of Derby, Self-
Addressed Stamped Envelope and Photo copy of Current Photo I.D.
CITY OF DERBY
Marc J. Garofalo, Town Clerk
1 Elizabeth Street - Derby, CT 06418
(203)736-1462
APPLICATION FOR BIRTH CERTIFICATE:
All issued Birth Certificates are certified with a raised seal.
Mark box A or B:
Long Form (Exact copy of original) - $20
Type A
(Required for Passport Applications and any institution requiring proof of parents)
Type B
Short Form (Wallet size) - $15
Fee: Cash Only when requested in person. Money order only when requested by mail.
Access to birth records less than 100 years old is restricted in Connecticut.
CURRENT PHOTOGRAPHIC IDENTIFICATION OF REQUESTER IS REQUIRED
(Driver’s License or Passport)
Photographic identification may be substituted by any two of the following documents:
Recent Paystub (showing name and address)
Current Automobile Registration (showing name & address)
Voter Registration card
Social Security Card
Recent copy of Utility bill (showing name & address)
Checking Account Deposit Slip (showing name & address)
I am applying for the Birth Certificate of:
Full Name at Birth: ______________________________________
My own birth certificate
(first, middle, last)
(16 or 17 years of age have access to wallet size only)
Date of Birth: __________________________________________
My child’s birth certificate
(month/day/year)
Place of Birth: __________________________________________
My parent’s birth certificate
(Town/State)
(must provide own long form birth certificate)
Father’s Full Name: ______________________________________
My spouse’s birth certificate
(first/middle/last)
(must provide marriage license)
Mother’s Full Maiden Name: ______________________________
My grandchild’s birth certificate
(first/middle/maiden last)
(must provide own child’s birth certificate)
My grandparents’s birth certificate
(must provide own & parent’s long form birth cert)
My client’s. I am the Attorney or Legal
Guardian
(must provide legal documentation)
Printed Name of Requester: ________________________________
Signature of Requester: ____________________________________
Address of Requester: ____________________________________________________________________________
Phone Number: __________________________________________
When mailing this form, please be sure to include the following items:
Original Application Form, Money Order for the total copies requested made payable to the City of Derby, Self-
Addressed Stamped Envelope and Photo copy of Current Photo I.D.
Popular Articles
- 2019 Tax Return Due Dates And Deadlines 2019 Tax Return Due Dates And Deadlines
- 2019 Tax Return Due Dates for Business Owners 2019 Tax Return Due Dates for Business Owners
- 2019 Tax Filing Deadlines for Individuals 2019 Tax Filing Deadlines for Individuals
- 2019 Payroll Tax Calendar for Employers 2019 Payroll Tax Calendar for Employers
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
Most popular documents
-
"Zappos Kid Shoe Size Chart"
-
"Vsepr Theory (Molecular Shapes) Chart"
-
DD Form 2813
-
DA Form 2062 "Hand Receipt/Annex Number"
-
"NATO Phonetic Alphabet Chart"
-
"Deed of Sale of Motor Vehicle Form" - Philippines
-
DD Form 1750 "Packing List"
-
DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
AF Form 910 "Enlisted Performance Report (AB Thru TSGT)"
-
DA Form 3595 "Record Fire Scorecard"
![](https://www.pinterest.com/pin/create/button/?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&media=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_big.png&description="Application Form for Birth Certificate" - City of Derby, Connecticut Download Pdf){kind=small}
Most popular documents
-
"Zappos Kid Shoe Size Chart"
-
"Vsepr Theory (Molecular Shapes) Chart"
-
DD Form 2813
-
DA Form 2062 "Hand Receipt/Annex Number"
-
"NATO Phonetic Alphabet Chart"
-
"Deed of Sale of Motor Vehicle Form" - Philippines
-
DD Form 1750 "Packing List"
-
DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
AF Form 910 "Enlisted Performance Report (AB Thru TSGT)"
-
DA Form 3595 "Record Fire Scorecard"
Popular Articles
- 2019 Tax Return Due Dates And Deadlines 2019 Tax Return Due Dates And Deadlines
- 2019 Tax Return Due Dates for Business Owners 2019 Tax Return Due Dates for Business Owners
- 2019 Tax Filing Deadlines for Individuals 2019 Tax Filing Deadlines for Individuals
- 2019 Payroll Tax Calendar for Employers 2019 Payroll Tax Calendar for Employers
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
![](http://api.addthis.com/oexchange/0.8/forward/facebook/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derby, Connecticut.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)
![](http://api.addthis.com/oexchange/0.8/forward/twitter/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derb...&via=templateroller&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)
![](http://api.addthis.com/oexchange/0.8/forward/pinterest_share/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derby, Connecticut.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)
![](http://api.addthis.com/oexchange/0.8/forward/reddit/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derby, Connecticut.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)
![](http://api.addthis.com/oexchange/0.8/forward/linkedin/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derby, Connecticut.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)
![](http://api.addthis.com/oexchange/0.8/forward/mailto/offer?url=https://www.templateroller.com/template/6253/application-form-birth-certificate-city-derby-connecticut.html&title=Download the latest PDF version of fillable "Application Form for Birth Certificate" - City of Derby, Connecticut.&description=Fill out, print and use this and thousands of other free templates at templateroller.com.&screenshot=https://data.templateroller.com/pdf_docs_html/6/62/6253/application-form-birth-certificate-city-derby-connecticut_print_big.png&pubid=ra-5bab7ed006800266&ct=1)