Minnesota Birth Record Application Form printable pdf download

MINNESOTA BIRTH RECORD APPLICATION – CERTIFICATE OF BIRTH

This application must be signed in the presence of a notary public or a local registrar.

If boxes are incomplete the application may not be processed.

Mail completed application and check payable to: Lac qui Parle County Recorder, 600 6

St. Ste4, Madison MN 56256

If you have questions, please e-mail

or call 320-598-3724.

PART I:

Birth Record Subject Information

FIRST NAME

MIDDLE NAME

LAST NAME (at BIRTH)

DATE OF BIRTH

GENDER

CITY and COUNTY OF BIRTH

MOTHER’S FIRST NAME

MIDDLE NAME

MAIDEN NAME

FATHER’S FIRST NAME

MIDDLE NAME

LAST NAME

PART II:

What is your relationship to the subject? (Please check only ONE.)

I am the subject.

I am the parent listed on the record.

I am the child of the subject.

I am the grandparent of the subject.

I am the spouse of subject.

I am the grandchild of the subject.

I am the health care agent of the subject (you must submit a Health

I am the party responsible for filing the birth record.

Care Agent Power of Attorney)

I am the legal custodian, guardian or conservator of the subject. (Must present certified copy of court order to this effect)

I am a personal representative and the certified copy is required for the administration of the estate (must submit a sworn affidavit)

I can demonstrate that the information from the record is necessary for the determination or protection of personal or property

rights pursuant to rules adopted by the commissioner of health. (you must submit documentation showing this relationship)

I represent an adoption agency and the record is needed to complete a confidential post-adoption search.(you must provide a

photocopy of your must show employee ID)

I am an attorney and have attached proof of my licensure

I am presenting your office with a certified copy of a court order

issued by a court of competent jurisdiction.

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 represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform

its authorized duties (please submit a photocopy of your employee ID)

I am a representative authorized by a person listed above. (Must present a notarized statement in addition to the application.)

PURPOSE FOR YOUR REQUEST:

PART III:

Requestor / Applicant Information:

FIRST NAME

MIDDLE NAME

LAST NAME (Current Legal Name)

DATE OF BIRTH

MAILING STREET ADDRESS ( If using a Post Office Box Number, you must also include a street address )

CITY

STATE

ZIP

DAYTIME PHONE NUMBER

E-MAIL ADDRESS

The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota

Rules, part 4601.2600.

certify that the information provided on this application is accurate and complete to the best of my knowledge and belief

Applicant Signature:

DATE

PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced up to 1 year in jail or a

fine of up to $3000 or both (Minnesota Statutes, sec.144.227 and sec.609.02, subd.3 & 4).

IF APPLYING IN PERSON, YOU MUST PRESENT A VALID AND CURRENT FORM OF PHOTO IDENTIFICATION

Signature must be notarized if applying by mail, email or fax.

For Administrative Use Only

Subscribed and sworn before me this ____day of _______, 20____

(Seal)

DL/ID at State of ________

DL/ID #

_____________________________________________________

______________________

(Notary Public Signature) My commission expires: _____________

Officer’s Initials__________

B10 2 REV 2/2012

Minnesota Birth Record Application Form

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