CLARK COUNTY HEALTH DEPARTMENT
1320 Duncan Ave.
Jeffersonville, IN 47130 – Phone # (812-282-7521)
*Application for Search and Certified
Include $10.00 Fee each, and Self
Copy of Birth Record
Addressed Stamped Envelope.
*ID Required (Of Applicant)
In accordance with State Law
IC 16-1-18 all request for Birth
By Mail: You may send a photo copy of
Certificates must include information
One of the following: Personal ID, Signed
requested below. A copy of this
Driver’s License, or Military ID.
request must be kept on file.
PLEASE PRINT (False application is a criminal offense under IC-1-19-6)
Full name at Birth_________________________________________________________
Could this birth be recorded in any other name? Yes_____No_____
If yes, Please give name______________________________________________
Has this person ever been adopted? Yes__________ No____________
If yes, Please give name after adoption__________________________________
Place of Birth: City___________________________ County_____________________
Date of Birth_________________________________ Age________________________
Full name of Father:______________________________ Birthplace________________
(If adopted, give name of adoptive father)
Full name of Mother:_____________________________ Birthplace________________
Maiden
(If adopted, give name of adoptive mother)
Purpose for which record is to be used:________________________________________
Your relationship to person whose birth record is requested:_______________________
Signature of Applicant_____________________________________________________
Mailing Address__________________________________________________________
City and State_________________________________________Zip________________
Phone number:___________________________________________________________
Total Certificates_____________________________Total Fees___________________