Application Form for Birth Certificate - City of Derby, Connecticut
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.
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.
