1
2MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH
This application must be signed in the presence of a notary public or a local registrar.
If boxes are incomplete the application may not be processed.
th
Mail completed application and check payable to: Lac qui Parle County Recorder, 600 6
St. Ste4, Madison MN 56256
If you have questions, please e-mail
recorder@lqpco.com
or call 320-598-3724.
PART I:
Birth Record Subject Information
FIRST NAME
MIDDLE NAME
LAST NAME (at BIRTH)
DATE OF BIRTH
GENDER
CITY and COUNTY OF BIRTH
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II:
What is your relationship to the subject? (Please check only ONE.)
I am the subject.
I am the parent listed on the record.
I am the child of the subject.
I am the grandparent of the subject.
I am the spouse of subject.
I am the grandchild of the subject.
I am the health care agent of the subject (you must submit a Health
I am the party responsible for filing the birth record.
Care Agent Power of Attorney)
I am the legal custodian, guardian or conservator of the subject. (Must present certified copy of court order to this effect)
I am a personal representative and the certified copy is required for the administration of the estate (must submit a sworn affidavit)
I can demonstrate that the information from the record is necessary for the determination or protection of personal or property
rights pursuant to rules adopted by the commissioner of health. (you must submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search.(you must provide a
photocopy of your must show employee ID)
I am an attorney and have attached proof of my licensure
I am presenting your office with a certified copy of a court order
issued by a court of competent jurisdiction.
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must
include a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform
its authorized duties (please submit a photocopy of your employee ID)
I am a representative authorized by a person listed above. (Must present a notarized statement in addition to the application.)
PURPOSE FOR YOUR REQUEST:
PART III:
Requestor / Applicant Information:
FIRST NAME
MIDDLE NAME
LAST NAME (Current Legal Name)
DATE OF BIRTH
MAILING STREET ADDRESS ( If using a Post Office Box Number, you must also include a street address )
CITY
STATE
ZIP
DAYTIME PHONE NUMBER
E-MAIL ADDRESS
The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota
Rules, part 4601.2600.
certify that the information provided on this application is accurate and complete to the best of my knowledge and belief
I
Applicant Signature:
DATE
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a
fine of up to $3000 or both (Minnesota Statutes, sec.144.227 and sec.609.02, subd.3 & 4).
IF APPLYING IN PERSON, YOU MUST PRESENT A VALID AND CURRENT FORM OF PHOTO IDENTIFICATION
Signature must be notarized if applying by mail, email or fax.
For Administrative Use Only
Subscribed and sworn before me this ____day of _______, 20____
(Seal)
DL/ID at State of ________
DL/ID #
_____________________________________________________
______________________
(Notary Public Signature) My commission expires: _____________
Officer’s Initials__________
3
B10 2 REV 2/2012
MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH
This application must be signed in the presence of a notary public or a local registrar.
If boxes are incomplete the application may not be processed.
th
Mail completed application and check payable to: Lac qui Parle County Recorder, 600 6
St. Ste4, Madison MN 56256
If you have questions, please e-mail
recorder@lqpco.com
or call 320-598-3724.
PART I:
Birth Record Subject Information
FIRST NAME
MIDDLE NAME
LAST NAME (at BIRTH)
DATE OF BIRTH
GENDER
CITY and COUNTY OF BIRTH
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II:
What is your relationship to the subject? (Please check only ONE.)
I am the subject.
I am the parent listed on the record.
I am the child of the subject.
I am the grandparent of the subject.
I am the spouse of subject.
I am the grandchild of the subject.
I am the health care agent of the subject (you must submit a Health
I am the party responsible for filing the birth record.
Care Agent Power of Attorney)
I am the legal custodian, guardian or conservator of the subject. (Must present certified copy of court order to this effect)
I am a personal representative and the certified copy is required for the administration of the estate (must submit a sworn affidavit)
I can demonstrate that the information from the record is necessary for the determination or protection of personal or property
rights pursuant to rules adopted by the commissioner of health. (you must submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search.(you must provide a
photocopy of your must show employee ID)
I am an attorney and have attached proof of my licensure
I am presenting your office with a certified copy of a court order
issued by a court of competent jurisdiction.
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must
include a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform
its authorized duties (please submit a photocopy of your employee ID)
I am a representative authorized by a person listed above. (Must present a notarized statement in addition to the application.)
PURPOSE FOR YOUR REQUEST:
PART III:
Requestor / Applicant Information:
FIRST NAME
MIDDLE NAME
LAST NAME (Current Legal Name)
DATE OF BIRTH
MAILING STREET ADDRESS ( If using a Post Office Box Number, you must also include a street address )
CITY
STATE
ZIP
DAYTIME PHONE NUMBER
E-MAIL ADDRESS
The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota
Rules, part 4601.2600.
certify that the information provided on this application is accurate and complete to the best of my knowledge and belief
I
Applicant Signature:
DATE
PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a
fine of up to $3000 or both (Minnesota Statutes, sec.144.227 and sec.609.02, subd.3 & 4).
IF APPLYING IN PERSON, YOU MUST PRESENT A VALID AND CURRENT FORM OF PHOTO IDENTIFICATION
Signature must be notarized if applying by mail, email or fax.
For Administrative Use Only
Subscribed and sworn before me this ____day of _______, 20____
(Seal)
DL/ID at State of ________
DL/ID #
_____________________________________________________
______________________
(Notary Public Signature) My commission expires: _____________
Officer’s Initials__________
3
B10 2 REV 2/2012
Certificate of Birth Fee Worksheet
FEE INFORMATION
FIRST
M.I.
LAST
Print name of person applying as it
appears on the application:
Quantity
Fee per
Total
Requested
item
Item (Name of Birth Record SUBJECT):
One/First certificate for each birth record
1
$26
$26
$19
Additional birth certificates for the same subject (optional)
$
each
Total Amount submitted by mail (personal or bank check, or money order only)
(you may also apply by fax or email and call our office with credit card
$
information: see our disclosures on our website at
www.lqpco.com/recorder.php
)
Instructions for Completing the Application for a Birth Certificate
and Fee Worksheet
Ordering a certificate of birth from Lac qui Parle County Local Registrar:
Minnesota has a standard certificate that contains the following information:
child’s name, date of birth, sex, city of birth, parents’ names and parents’ birth places.
Minnesota no longer has a “long” form or photocopy certificate. However, you can request a
non-certified copy of a birth record that gives you more information about the birth.
The office of the State Registrar does not issue apostilles. You may request an apostille from the
Minnesota Secretary of State’s office.
A separate application must be completed for each individual’s birth record.
Your application could be returned for more information if boxes are left incomplete.
Part 1
Please make sure that all boxes are complete to the best of your knowledge.
If we cannot positively identify the birth record, you will receive a notice that there is not a
registration.
If adopted, use your adoptive name and adoptive parents’ names.
Part II
You must check only one of the relationships in this section.
If you are the subject and your parents were not married at the time of your birth, you must
be 16 to obtain your certificate.
The parties responsible for filing the birth record are:
Hospital
Midwife
Parent if child is born at home without a midwife.
Please attach additional documentation of proof when requested on the application.
(Example: Court ordered custody)
Part III
The person listed in part III is the person applying for the certificate.
If you do not have a phone or email address, please enter “none” in that box.
You must sign the application in the presence of a notary.
Your signed date and the notary date must be the same.
The notary stamp must be clear on the application unless your state does not provide a
notary stamp or seal.
If you have questions, please email
recorder@lqpco.com or call 320-598-3724
3
B10 2 REV 2/2012
