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3MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH
This application must be notarized or signed in the presence of a registrar.
If boxes are incomplete, the application may not be processed.
If you have questions, call Kandiyohi County Recorder at 320-231-6223.
The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
PART I: Name on Birth Record
FIRST NAME
MIDDLE NAME
LAST NAME
BIRTH MONTH
BIRTH DAY
BIRTH YEAR
SEX
CITY and COUNTY OF BIRTH
Choose M/F
-
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: Requester Information
NAME (Please Print)
DATE OF BIRTH
MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O. addresses)
CITY
STATE
ZIP
DAYTIME PHONE
EMAIL
PART III: What is your relationship to the subject of the record (tangible interest)? You must check one.
I am the subject of the record
I am the child of the subject
I am the spouse of the subject
I am a parent listed on the record
I am the grandparent of the subject
I am the grandchild of the subject
I am the party responsible for filing the birth record
I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a court order showing
this relationship)
I am the health care agent of the subject (you must submit a heath care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate (you must submit a sworn
affidavit of the fact that the certified copy is required for administration of the estate)
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 have documentation that the record is necessary for the determination or protection of personal or property rights (you must
submit documentation showing this relationship) (Submit to Minnesota Department of Health)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please submit a copy of
your employee ID)
I am an attorney and I have attached proof of my licensure
I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified copy)
I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to perform its
authorized duties (please submit a copy of your employee ID and valid Driver’s license)
I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a person
listed on the birth record)
PURPOSE FOR YOUR REQUEST (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)
REQUESTER’S SIGNATURE
DATE
Signed or attested before me on ________ day of __________________, 20________
NOTARY PUBLIC SIGNATURE
NOTARY STAMP/SEAL
MY COMMISSION EXPIRES:
Rev 01/09/12
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MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH
This application must be notarized or signed in the presence of a registrar.
If boxes are incomplete, the application may not be processed.
If you have questions, call Kandiyohi County Recorder at 320-231-6223.
The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
PART I: Name on Birth Record
FIRST NAME
MIDDLE NAME
LAST NAME
BIRTH MONTH
BIRTH DAY
BIRTH YEAR
SEX
CITY and COUNTY OF BIRTH
Choose M/F
-
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: Requester Information
NAME (Please Print)
DATE OF BIRTH
MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O. addresses)
CITY
STATE
ZIP
DAYTIME PHONE
EMAIL
PART III: What is your relationship to the subject of the record (tangible interest)? You must check one.
I am the subject of the record
I am the child of the subject
I am the spouse of the subject
I am a parent listed on the record
I am the grandparent of the subject
I am the grandchild of the subject
I am the party responsible for filing the birth record
I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a court order showing
this relationship)
I am the health care agent of the subject (you must submit a heath care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate (you must submit a sworn
affidavit of the fact that the certified copy is required for administration of the estate)
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 have documentation that the record is necessary for the determination or protection of personal or property rights (you must
submit documentation showing this relationship) (Submit to Minnesota Department of Health)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please submit a copy of
your employee ID)
I am an attorney and I have attached proof of my licensure
I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified copy)
I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to perform its
authorized duties (please submit a copy of your employee ID and valid Driver’s license)
I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a person
listed on the birth record)
PURPOSE FOR YOUR REQUEST (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)
REQUESTER’S SIGNATURE
DATE
Signed or attested before me on ________ day of __________________, 20________
NOTARY PUBLIC SIGNATURE
NOTARY STAMP/SEAL
MY COMMISSION EXPIRES:
Rev 01/09/12
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Certificate of Birth Fee Worksheet
FEE INFORMATION
FIRST
MIDDLE
LAST
Print name of person applying as it
appears on the application:
Number
Item
each
Total
Fee for
Requested
Per certificate for each birth record
$26 $
Additional fee for same certificate in the same order
$19 $
Optional – Credit Card Requests
$ 7.00
$
Vital Check Credit Card System
(Per Order)
United Parcel Service Mail Service is $17.50 for most deliveries.
$17.50
$
(Per Order)
Total amount included:
$
Check
(No out of
Credit Card
Please mark form of payment:
State
Money Order
(No Debit Cards)
Checks
Accepted)
Mail the completed, signed and notarized application form, birth certificate fee worksheet, copy of your valid
driver’s license or state issued ID, and check, credit card information, or money order to:
Kandiyohi County Recorder
400 Benson Ave SW
PO Box 736
Willmar MN 56201
Checks returned for non-payment will be charged a $30 fee according to Minnesota Statutes, section
604.113, subdivision 2 and civil penalties may be imposed for non-payment.
OR
Fax the completed form, birth certificate fee worksheet, credit card (Mastercard, VISA and Discover Card)
number, three digit security code, and expiration date to 320-231-6284.
Credit Card Users: Please print clearly
Credit card number:
Expiration date:
Three digit security code on back of card:
If you have questions, please call 320-231-6223.
Rev 07/29/11
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Instructions for Completing the Application for a Birth
Certificate and Fee Worksheet
Ordering a certificate of birth from the Kandiyohi County Recorder:
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.
Attach a fee worksheet for each separate order.
If the certificate is to be mailed outside of the continental US or to Hawaii or Alaska, and UPS service is
being used, please contact UPS for correct fees before mailing the application.
There is an additional fee for the same certificate ordered in the same order of $19.
Mail or fax your application, fee sheet and payment to our office according to the instructions on the
fee worksheet.
If you have questions, please call 320-231-6223.
Rev 01/09/12
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