Confidential Intermediary Application Form
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1Colorado Department of Public Health and Environment
Return
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Vital Records
Completed
Adoption Specialist
SF# _____- __________
Application to:
4300 Cherry Creek Drive South,
Denver CO 80246
AD: ____/____/____
Confidential Intermediary Application
For a certified copy of Adoptee’s Original Birth Certificate from a sealed adoption file or birth
certificate with adoptive information
Please submit the following:
Completed Application
Submit the correct fee
Certified order of appointment of confidential intermediary
Photocopy of your valid driver’s license
Photocopy of your confidential intermediary identification
If the court order allows photocopying of documents, a certified copy of the original birth certificate will be issued. If the court
order does not allow photocopying, you may only view the record.
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Type or print.
Provide birth information for individual whose original birth certificate is being requested.
Full Name at Birth
First
Middle
Last
Date of Birth
Month
Day
Year
Place of Birth
City
County
State
COLORADO ONLY
Birth Father’s Full
First
Middle
Last
Name
Birth Mother’s Name
First
Middle
Maiden Last Name
(Name Prior To First Marriage)
Prior To Marriage
Full Name of Adoptee
First
Middle
Last
(after adoption)
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Print Name
First
Middle
Last
Mailing Address
City
State
Zip
Email Address
Daytime Phone Number
Date
Signature of Confidential Intermediary
. Expedite service is available for an additional $20
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fee. Processing time for expedite requests is 15 days from date received.
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S - All fees are nonrefundable
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Apply in person. Office hours are from 8:30 a.m. 4:30 p.m., M-F.
Fax your application with credit card information: U.S. fax 800.423.1108;
$ 37.75_
Original birth certificate:
outside U.S. fax 303.691-9307.
with check, money order, or credit card information.
$ 17.75_
Mail in application
Adoptive birth certificate currently on file
Make check or money order payable to: Vital Records. Please do not send cash
.
(√) Check box
Additional Services:
❒ $20 Expedite Service Fee
$_______
Card Type: ❒ Visa ❒ Mastercard ❒ Discover ❒ American Express
within continental U.S. ($20.00)
❒ Fed Ex
–
$_______
Cardholder Name:________________________________________
within continental U.S. ($18.30)
❒Express Mail
–
$_______
Card Number:
|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
Exp. Date:
_____/_________
$_______
Total............................................................................
Rev. 03/2014 SV
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