Application To Request A Birth Certificate - Utah Vital Records
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2UTAH DEPARTMENT OF HEALTH
OFFICE OF VITAL RECORDS AND STATISTICS
288 NORTH 1460 WEST (PHYSICAL ADDRESS)
PO BOX 141012 (MAILING ADDRESS)
SALT LAKE CITY UT 84114-1012
PHONE (801) 538-6105 • FAX (801) 538-7012
ONLINE REQUEST can be found at silver.health.utah.gov
BIRTH CERTIFICATE REQUEST FORM
VITAL RECORDS
Certificates available: Births that occurred in Utah from 1905 - present.
VALIDATION ONLY
WARNING: It is a criminal violation to make false statements on vital records request forms or to
fraudulently obtain a vital records certificate.
Instructions:
You can use our online application at silver.utah.gov. If not completed online, an application must be
1.
completed for each individual's certificate separately. Please verify you are using the most updated form
by looking online at health.utah.gov
2.
ID is REQUIRED of the person that signs this request. ID must be either a government issued photo ID, or
two other proofs (see list of acceptable identifications on reverse). If request is presented in person,
provide ID to clerk. If request is mailed, include a legible COPY of a nonexpired ID.
3.
Please check your certificate(s) for accuracy. Your certificate can be replaced within 90 DAYS from the
issuance date. After 90 days, you must repay applicable fees. If requestor does not respond to a written
request for information within 90 days, Vital Records may retain all monies paid.
IDENTIFYING INFORMATION
FULL NAME ON CERTIFICATE
BIRTH INFORMATION
(DATE)
(CITY)
(COUNTY)
(HOSPITAL/PLACE OF BIRTH)
PARENT 1 INFORMATION
(FULL NAME, MAIDEN NAME IF APPLICABLE)
(BIRTH DATE)
(STATE OR COUNTRY)
PARENT 2 INFORMATION
(FULL NAME, MAIDEN NAME IF APPLICABLE)
(BIRTH DATE)
(STATE OR COUNTRY)
REQUESTOR
RELATIONSHIP:
SELF
PARENT
SIBLING
SPOUSE
CHILD
GRANDPARENT
GRANDCHILD
OTHER (SPECIFY)
PRINTED NAME
PHONE #
ADDRESS
EMAIL ADDRESS
SIGNATURE
DATE
PURPOSE FOR WHICH CERTIFICATE IS NEEDED
NEED A CERTIFIED COPY OF THE VOLUNTARY DECLARATION OF PATERNITY
IS THE INDIVIDUAL STILL LIVING
YES
NO
NUMBER OF CERTIFICATES REQUESTED
+
1
SEARCH (NON REFUNDABLE) INCLUDES 1 CERTIFIED COPY
$
20.00
ADDITIONAL CERTIFIED COPIES ($10.00 EACH)
$
TOTAL FEE
$
OFFICE USE ONLY (DO NOT WRITE BELOW)
PAID:
CHECK
CASH
MONEY ORDER
CREDIT CARD(IN PERSON ONLY)
WAIT
MAIL
PICK UP
CLERK'S INITIALS
ID
ID EXP
REQUEST #
revision 6.8.16
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