Form 45-13a - Oregon Birth Record Order Form Page 2
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1
2
3Oregon Birth Record
ORDER FORM
Number of certified records requested.
Center for Health Statistics
QUANTITY
$25 first record/$20 each additional copy
of the same record ordered at the same time.
1. Full name on record:
(first)
(middle)
(last)
2. Date of birth:
3. Sex:
4. Place of birth:
OREGON
(mm/dd/yyyy)
(M or F)
(city)
(county)
OFFICE USE ONLY
5. Mother/Parent A’s legal birth name:
DO NOT WRITE IN THIS SPACE
(maiden name )
(first)
(middle)
(last name at mother’s birth/maiden name)
Certificate number:
6. Father/Parent B’s full name:
(first)
(middle)
(last)
7. Your relationship to person named in line 1:
8. Reason for needing record:
9. Daytime telephone number:
10. Email:
11. Name of person ordering:
1
2
Film
Film (P)
12. Your address:
Computer
Indexes
13. City/State/ZIP:
Index (P)
DF/CO
14. c Person ordering: Attach legible photocopy of current, valid ID or legal representative
document and representative’s ID. See back of form for alternative ID options.
Refund: $
15. Required signature of person ordering:
Excess fee
Out/state
No record
Uncompleted
In accordance with law — ORS 432.380, only the person named on the record, immediate
Check #:
family members, legal representatives and government agencies are eligible to access birth
records. For all others, access to birth records is restricted for 100 years. Legal guardians
File date:
Amendment fee:
must enclose a copy of the legal document and representative’s ID. If you are not eligible,
enclose a written permission note with a notarized signature of an eligible person.
Full issued:
NRL/ref. issued:
Send to:
Make checks/money orders payable to:
OREGON VITAL RECORDS
OHA/Vital Records
Follow-up:
Computer copy:
PO BOX 14050
PLEASE DO NOT SEND CASH
PORTLAND OR 97293-0050
Checks/money orders in U. S. Dollars
Non-Sufficient Funds (NSF) check
WARNING : Providing false information is a felony under ORS 432.993.
processing policy: In the event that your
check is returned unpaid for insufficient
$25 FOR THE FIRST RECORD; $20 FOR EACH ADDITIONAL COPY OF THE SAME
or uncollected funds, we may present
RECORD ORDERED AT THE SAME TIME. The $25 fee is non-refundable once the
your check electronically. In the ordinary
search for the record has been completed. Administrative Rule OAR 333-011-0340(1).
course of business, your check will
not be provided to you with your bank
This form available in alternative formats. See back for details.
statement, but a copy can be retrieved
by other means. A penalty, not to exceed
ENTER YOUR MAILING ADDRESS
$35, may be assessed for NSF checks
THIS SECTION WILL BE DETACHED AND USED AS A MAILING LABEL
per ORS 30.701(5).
See second page of form for
Name
ordering options and processing times.
Street
Information is also available on our Web
page at: or
City
State
ZIP
by calling 971-673-1190.
45 -13A (01/16)
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