"Certificate of Birth Form" - Kandiyohi County, Minnesota

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Certificate of Birth Form is a legal document that was released by the County Recorder - Kandiyohi County, Minnesota - a government authority operating within Minnesota. The form may be used strictly within Kandiyohi County.

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Released on January 9, 2012;
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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

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