Form Vs-11 - Arizona Vital Records Request For Copy Of Birth Certificate
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Arizona Vital Records Request for Copy of Birth Certificate
For Office Use Only—State File Number/Serial Number
Request iD
CUSTOMER ChECkliST
Please visit the State Office of Vital Records website for
the following information:
Clear photocopy of the front and back of your valid, signed
2
government photo ID OR have your signature notarized
• Fees
• Locations, office hours, and availability of services
Proof of relationship enclosed if required (birth certificates,
2
• Eligibility requirements and acceptable identification
certified court documents, etc)
• Correction, amendment, and registration information
Sign the application
2
• Download forms
Include self-addressed stamped envelope
2
Telephone: 602-364-1300
Apply Online:
(Refer to website for their current fees)
Correct fee enclosed
2
Today's Date
# of Certified Copies Requested
Purpose of Request
Payment Method
Payment information
Card Number _______ - _______ - _______ - _______
Card Expiration Date
/
2 Visa
2 MC
Signature of Cardholder
Amount to be Charged
— Must provide photocopy of valid government issued identification if cardholder is not the applicant.
$
Date of Birth
Sex
Name on Birth Certificate
2 Male
2 Female
First
Middle
last
Town/City of Birth
County
hospital
Mother's/Parent's First Name
Middle
Last Name prior to first marriage
Date of Birth
State (if US) or Country of birth
Father's/Parent's First Name
Middle
last
Date of Birth
State (if US) or Country of birth
Do you belong to an Arizona Tribe?
if yes, please specify tribe.
2 Yes
2 No
Applicant's Full Name—Printed
Applicant's
Signature—Required
First
Middle
last
Mailing Address
Street
City
State
Zip
Daytime Telephone Number
Email Address
Your Relationship to Person on Certificate—Check One
*PROOF of relationship MUST be provided if you are NOT named on the certificate.
2 Parent 2 Self 2 Brother/Sister 2 Grandparent 2 Legal Guardian 2 Spouse 2 Gov't Agency 2 Other
State of
County of
On this
day of
, 20
before me personally appeared
(name of signer), whose identity was proven to me
Affix Seal/Stamp Here
on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who
acknowledges that he/she signed the above document.
Notary Signature
My Commission Expires
VS-11 (05/15)
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