Minnesota Birth Record Application Form - Certificate Of Birth
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3MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH
This application must be notarized or signed in the presence of a registrar.
If boxes are incomplete, the application may not be processed.
If you have questions, call Kandiyohi County Recorder at 320-231-6223.
The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
PART I: Name on Birth Record
FIRST NAME
MIDDLE NAME
LAST NAME
BIRTH MONTH
BIRTH DAY
BIRTH YEAR
SEX
CITY and COUNTY OF BIRTH
Choose M/F
-
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: Requester Information
NAME (Please Print)
DATE OF BIRTH
MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O. addresses)
CITY
STATE
ZIP
DAYTIME PHONE
EMAIL
PART III: What is your relationship to the subject of the record (tangible interest)? You must check one.
I am the subject of the record
I am the child of the subject
I am the spouse of the subject
I am a parent listed on the record
I am the grandparent of the subject
I am the grandchild of the subject
I am the party responsible for filing the birth record
I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a court order showing
this relationship)
I am the health care agent of the subject (you must submit a heath care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate (you must submit a sworn
affidavit of the fact that the certified copy is required for administration of the estate)
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must include a
sworn affidavit of the fact that the certified copy is required for administration of the estate)
I have documentation that the record is necessary for the determination or protection of personal or property rights (you must
submit documentation showing this relationship) (Submit to Minnesota Department of Health)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please submit a copy of
your employee ID)
I am an attorney and I have attached proof of my licensure
I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified copy)
I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to perform its
authorized duties (please submit a copy of your employee ID and valid Driver’s license)
I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a person
listed on the birth record)
PURPOSE FOR YOUR REQUEST (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)
REQUESTER’S SIGNATURE
DATE
Signed or attested before me on ________ day of __________________, 20________
NOTARY PUBLIC SIGNATURE
NOTARY STAMP/SEAL
MY COMMISSION EXPIRES:
Rev 01/09/12
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