Indiana Certificate Of Live Birth Worksheet Template (Page 2 of 12) in pdf

1 1 1 1 1 1 1 1 . What will be your

. What will be your BABY

BABY’ ’ ’ ’ S S S S legal name (as it should appear on the birth certificate)?

legal name (as it should appear on the birth certificate)?

. What will be your

BABY

legal name (as it should appear on the birth certificate)?

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

First

Middle

Last

Suffix (Jr., III, etc.)

1 1 1 1 2 2 2 2 . MOTHE

. MOTHE

. MOTHER: What is your current legal name?

. MOTHE

R: What is your current legal name?

_______________________ _________________ _______________________ ____________

First

Middle

Last

Suffix (Jr., III, etc.)

1 1 1 1 3 3 3 3 . . . . MOTHER: Where do you usually live

MOTHER: Where do you usually live

MOTHER: Where do you usually live-- -- -- --that is

that is

that is-- -- -- --where is your household/residence

that is

where is your household/residence

where is your household/residence located?

located?

Building number: ______________________ Pre-directional ___________________________________

Name of street _______________________________________________________________________

Street Designator, eg Street, Avenue, etc. _______________________________

Post Directional __________________________________ Apartment Number _____________

State: _______________________(or U.S. Territory, Canadian Province)

If not United States, Country ________________________________________

City, Town, or Location:_______________________________ County: _______________________ Zip: _______________

1 1 1 1 4 4 4 4 . Is this household inside city limits (inside the incorporated limits of the city, town or location

. Is this household inside city limits (inside the incorporated limits of the city, town or location

where you

where you live)?

live)?

where you

live)?

Yes

Don’t know

Same as residence [Go to next question]

1 1 1 1 5 5 5 5 . M O T H E R :

. M O T H E R :

W h a t i s y o u r m a i l i n g a d d r e s s ?

Building number: ______________________ Pre-directional ___________________________________

Name of street _______________________________________________________________________

Street Designator, eg Street, Avenue, etc. _______________________________

Post Directional __________________________________ Apartment Number _____________

State: _______________________(or U.S. Territory, Canadian Province)

If not United States, Country ________________________________________

City, Town, or Location:_______________________________ County: _______________________ Zip: _______________

1 1 1 1 6 6 6 6 . MOTHER: What is your date of birth? (Example: 03

. MOTHER: What is your date of birth? (Example: 03

. MOTHER: What is your date of birth? (Example: 03- - - - 04

. MOTHER: What is your date of birth? (Example: 03

04- - - - 1977)

1977)

___ ___/___ ___/___ ___ ___ ___

M M D D Y Y Y Y

AGE: ________________

1 1 1 1 7 7 7 7 . MOTHER: In what State, U.S. territory, or foreign country were you born?

. MOTHER: In what State, U.S. territory, or foreign country were you born?

. MOTHER: In what State, U.S. territory, or foreign country were you born? Please specify one

. MOTHER: In what State, U.S. territory, or foreign country were you born?

Please specify one

of the following:

State ___________________________________County ____________________________ City ___________________________

OR U.S. territory, i.e., Puerto Rico, U.S. Virgin Islands, Guam, American Samoa or Northern Marianas

___________________________ OR Foreign country ___________________________________________

UNKNOWN

1 1 1 1 8 8 8 8 . MOTHER: What is your Social Secur

. MOTHER: What is your Social Secur

. MOTHER: What is your Social Security Number?

. MOTHER: What is your Social Secur

ity Number?

__ __ __ ___ _ _ _ __ __ __ ___ _ _ _ ____

______ __ __ __ ____

______ __ __ __-- -- -- --- - - - _ _ _ _ ____

_____ _

_ _____

_____ _ _ _ -- -- -- --- - - - _ _ _ _ ____

_____ _ _ _ ____

______ _

__ _____

_____ _

_ _____

_____ _ _ _

____

_ _

____

__ _

____

_ _

____

1 1 1 1 9 9 9 9 . Do you want a Social Security Number issued for your baby?

. Do you want a Social Security Number issued for your baby?

Yes (Please sign request below)

No (Continue)

I r e q u e s t t h a t t h e S o c i a l S e c u r i t y A d m i n i s t r a t i o n a s s i g n a S o c i a l S e c u r i t y n u m b e r t o t h e c h i l d n a m e d o n t h i s f o r m a n d a u t h o r i z e t h e S t a t e t o p r o v i d e

t h e S o c i a l S e c u r i t y A d m i n i s t r a t i o n w i t h t h e i n f o r m a t i o n f r o m t h i s f o r m w h i c h i s n e e d e d t o a s s i g n a n u m b e r . ( E i t h e r p a r e n t , o r t h e l e g a l g u a r d i a n , m a y

s i g n . )

Signature of infant’s mother or father_____________________________________________________

Date: ___ ___/___ ___/___ ___ ___ ___

M M D D Y Y Y Y

5/25/2012

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VERSION 27 INDIANA'S BIRTH WORKSHEET