Fillable Electronic Birth Certification Request printable pdf download

DL 57 (02/10/2014)

ELECTRONIC BIRTH CERTIFICATION REQUEST

U.S. VITAL RECORDS AGENCIES

Purpose:

Persons born in a U.S. state (see page 2) use this form to request an electronic certification of a birth if they do not have a

paper birth certificate when applying for a Virginia Driver's License (DL) or Identification Card (ID).

Instructions: Submit completed form, necessary proof of identity documents (see page 2) and applicable fees (see page 2) to any DMV

customer service center. NOTE: Fees paid for a birth certification are non-refundable.

REQUESTER INFORMATION

REQUESTER NAME - AGE 18 AND OLDER (print) (first)

(middle )

(last)

(suffix)

TELEPHONE NUMBER

(

)

STATE

ZIP CODE

REQUESTER ADDRESS

CITY

INDICATE YOUR RELATIONSHIP TO THE PERSON NAMED ON THE BIRTH CERTIFICATE (check one)

SELF

MOTHER

FATHER

LEGAL GUARDIAN ( must submit copy of custody order)

WHAT IS YOUR REASON FOR REQUESTING BIRTH CERTIFICATION? (check one)

IDENTIFICATION CARD

DRIVER'S LICENSE

LEARNER'S PERMIT

BIRTH CERTIFICATE INFORMATION

FULL NAME AS IT APPEARS ON BIRTH CERTIFICATE (print) (first)

( middle)

(last)

(suffix)

BIRTH DATE (mm/dd/yyyy)

NOTE - Electronic certification is ONLY available

GENDER ON BIRTH CERTIFICATE

PARTICIPATING BIRTH STATE (from chart on page 2)

for the participating states indicated in the chart on page 2.

MALE

FEMALE

If your birth state is participating enter the state name here.

MOTHER'S MAIDEN NAME (print) (first)

(middle)

(last)

FATHER'S SURNAME/LAST NAME (optional)

NOTE:

Non-Virginia born certification - the certification of a birth in a non-Virginia jurisdiction does not include issuance of a birth certificate. You must

contact the state for details on obtaining a birth certificate.

Virginia born certification - the certification of a birth in Virginia includes issuance of a Virginia birth certificate. The certificate will be sent to the

Requester Address above unless you provide an alternate mailing address below.

ALTERNATE MAILING ADDRESS

CITY

STATE

ZIP CODE

CERTIFICATION

I agree to pay the state fee and the $2.00 administrative fee necessary to conduct a birth certification (see page 2). I certify and affirm that all information

presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting

documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false

statement or representation on this form is a criminal violation.

REQUESTER SIGNATURE

DATE (mm/dd/yyyy)

REQUIREMENTS FOR ACCEPTABLE DOCUMENTS

Documents must be originals. Temporary documents and photocopies will not be accepted.

All documents are subject to verification with the issuing entity, which may delay the issuance of your certification.

A document will not be accepted when there is reason to believe it has been altered, fraudulently obtained or is fake, forged, counterfeit, or otherwise non-

genuine or illegitimate. Altering, manufacturing, selling or possessing a fraudulent birth certificate, driver’s license or ID card, falsifying information or

assisting a person with improperly or fraudulently obtaining a certification is a criminal offense.

Name: Make sure that your name appears the same on all proof documents. If your middle name or middle initial begins with the same letter, but is not

spelled out or displayed on all of your documents, your documents may be accepted. Nicknames will not be accepted. If your name appears differently on

your proof documents, you may be asked to present additional documentation.

The list of acceptable documents may change without prior notice.

DMV USE ONLY

DMV CUSTOMER NUMBER

IDENTIFICATION DOCUMENTS PRESENTED (CSR must indicate one primary or 2 secondary documents from the list on page 2)

CSR STAMP