Minnesota Birth Record Application Form Page 2

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Certificate of Birth Fee Worksheet
FEE INFORMATION
FIRST
M.I.
LAST
Print name of person applying as it
appears on the application:
Quantity
Fee per
Total
Requested
item
Item (Name of Birth Record SUBJECT):
One/First certificate for each birth record
1
$26
$26
$19
Additional birth certificates for the same subject (optional)
$
each
Total Amount submitted by mail (personal or bank check, or money order only)
(you may also apply by fax or email and call our office with credit card
$
information: see our disclosures on our website at
)
Instructions for Completing the Application for a Birth Certificate
and Fee Worksheet
Ordering a certificate of birth from Lac qui Parle County Local Registrar:
Minnesota has a standard certificate that contains the following information:
child’s name, date of birth, sex, city of birth, parents’ names and parents’ birth places.
Minnesota no longer has a “long” form or photocopy certificate. However, you can request a
non-certified copy of a birth record that gives you more information about the birth.
The office of the State Registrar does not issue apostilles. You may request an apostille from the
Minnesota Secretary of State’s office.
A separate application must be completed for each individual’s birth record.
Your application could be returned for more information if boxes are left incomplete.
Part 1
Please make sure that all boxes are complete to the best of your knowledge.
If we cannot positively identify the birth record, you will receive a notice that there is not a
registration.
If adopted, use your adoptive name and adoptive parents’ names.
Part II
You must check only one of the relationships in this section.
If you are the subject and your parents were not married at the time of your birth, you must
be 16 to obtain your certificate.
The parties responsible for filing the birth record are:
Hospital
Midwife
Parent if child is born at home without a midwife.
Please attach additional documentation of proof when requested on the application.
(Example: Court ordered custody)
Part III
The person listed in part III is the person applying for the certificate.
If you do not have a phone or email address, please enter “none” in that box.
You must sign the application in the presence of a notary.
Your signed date and the notary date must be the same.
The notary stamp must be clear on the application unless your state does not provide a
notary stamp or seal.
If you have questions, please email
or call 320-598-3724
3
B10 2 REV 2/2012

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