Form Dhhs-Vr-B - Application For A Copy Of A North Carolina Birth Certificate
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1
2North Carolina Department of Health and Human Services
Division of Public Health • N.C. Vital Records
Telephone: 919-733-3000
Mail:
1903 Mail Service Center
Location:
225 North McDowell St.
Raleigh, NC 27699-1900
Raleigh, NC 27603-1382
Application for a Copy of a North Carolina Birth Certifi cate
PLEASE PRINT
Certifi cate Information
Full Name on Certifi cate
_________________________________________________________________
First Name
Middle Name
Last Name
(If adopted, provide new information)
Date of Birth
____ | ____ | ________
Sex Male Female
Month
Day
Year
Were parents married at time of birth?
Place of Birth
_________________________________________
Yes No
City
County
Is this person deceased? Yes No
Full Name of Mother/Parent
___________________________________________________________________
(Adoptive parent, if applies)
First Name
Middle Name
Last Name
Last Name prior to fi rst marriage, if applies
Full Name of Father/Parent
___________________________________________________________________
(Adoptive parent, if applies)
First Name
Middle Name
Last Name
Last Name prior to fi rst marriage, if applies
Check all boxes that apply; add the fees in 1–3
Your Relationship to the Person Whose Certifi cate is Requested:
and place the total amount in #4.
(Check one)
See further instructions on Page 2.
1. Order Certifi cate
Self
Authorized agent, attorney or legal representative of
the person listed (Proof REQUIRED)
Processing times vary.
Spouse (Current)
Check website for current information.
Other (may not be entitled to a certifi ed copy)
Brother/Sister
(Non-refundable fee)
Specify ____________________________________
Child
Certifi cate Search and First Copy ($24)
$ ______
______________________________________________
Parent/Step-Parent
#___ additional copies x $15
$ ______
Grandparent
______________________________________________
Certifi ed (Legally suitable for any purpose)
Uncertifi ed (Suitable for research purposes)
How do you plan to use this record? _____________________________________
2. Record Changes (Only if applies)
__________________________________________________________________
Appointment required for in-person services.
(Please Print)
($15 non-refundable processing fee)
Requestor: ______________________________________________________________
Adoption
$ ______
Print Name of Person Requesting a Certifi cate
Amendment
$ ______
Address:
______________________________________________________________
Name Change
$ ______
Street Address (P.O. Box cannot be used for expedited shipping)
Legitimation Court Order
$ ______
_________________________________________________________________________
Legitimation (mother married father
P.O. Box (If mailing to a P.O. Box, street address must also be listed above)
after child’s birth)
$ ______
_________________________________________________________________________
Paternity (no fee)
$
00.00
City, State, Zip Code
Other _____________________
$ ______
_________________________________________________________________________
3. Faster Service (Choose only one)
(Area Code) Telephone Number (During business hours)
Optional for mail-in requests
($15 non-refundable expedite fee)
Email Address: ___________________________________________________________
Walk-in Service ($15)
$ ______
Payment: Please pay with a cashier’s check or money order made payable to N.C. Vital
Expedited Processing ($15)
$ ______
Records. Personal checks are not accepted. Requests that are submitted with no payment,
(Shipped by regular mail)
or incomplete payment or incomplete information will be returned. Credit card payment is
Expedited Processing and
available for walk-in customers.
Expedited Shipping ($35)
$ ______
(Call for expedited shipping fees outside the continental United States)
ID OF THE PERSON REQUESTING A CERTIFICATE IS REQUIRED:
4. Total Fees
See Page 2 for a list of acceptable IDs. Requests that do not include proper identifi cation
(Add 1+2+3 above for total)
$ ______
will be returned.
I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of N.C. Law (G.S. 130A-26A) to
make a false statement on this application or to unlawfully obtain a copy or a certifi ed copy of a birth certifi cate.
___________________________________________________________
______________________________________________
Signature of Person Requesting a Certifi cate
Date
Offi ce Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame _______________________________________
Amount received: $_______________________ Identifi cation presented_______________________________________________________________________________
Request number ___________________________________________ Request date _____________________________________________________________________
DHHS-VR-B (Revised 11/2016)
N.C. Vital Records (Review 11/2019)
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