Birth Certificate Request Form
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1
2Birth Certificate Request
Division of Vital Records
th
Phone: (405) 271-4040
1000 NE 10
Street
Walk-in Hours: Mon-Fri 8:30-4:00
Oklahoma City, OK 73117
Requirements:
1) This request must be completed in full.
2) Enclose a copy of a current legal photo ID (See back for list of acceptable IDs)
3) Enclose appropriate fees
4) Person requesting to receive a birth certificate must sign below
5) If submitting by mail, enclose a self-addressed stamped envelope
Full Name at Birth:
(If a change to the name has occurred, please see instruction sheet)
_________________________
_____________________________
_____________________________________
First
Middle
Last
Date of Birth: _____ / ______ / _____
Female
Male
Place of Birth: ______________________ , OKLAHOMA
Month
Day
Year
City and/or County
Full Name of Father: ____________________
________________________ _______________________
First
Middle
Last
Full MAIDEN Name of Mother: _________________
________________
________________________________
First
Middle
Last Name prior to first marriage
This request is being made by:
Person Himself/Herself
Parent
Legal Guardian or Custodian
Authorized Agent, must specify: __________________________________
Current Address (REQUIRED):
Name ___________________________________________________________
Daytime Telephone Number: (________) _______ - ________________
Street Address _______________________________________________Apt _______
City, State and Zip ______________________________________
Purpose for which the birth certificate is needed:
Drivers License
Social Security
Passport
School
State Assistance Pgm
Other, specify: _______________________________
By signing below, I declare that all information provided on this request is true and correct.
Signature: __________________________________________________________
Date Signed: _________________________________
(Request will not be processed without the signature of the requestor and established eligibility.)
Fees
A fee is to be paid for a search of the files or records, even when no copy is available. Search fees are non-transferable and non-refundable.
_______ Number of certified copies requested ($15 each and includes search fee)
_______ Delayed registration, amendment, paternity, adoption, or legitimation fee ($40 - Includes one certified copy)
_______ Number of Heirloom certificates requested: ($35 each and includes one certified copy)
_______ Total Amount enclosed
Make checks payable to OSDH. Do not send cash by mail.
Print Form
Mailing address: Division of Vital Records, PO Box 53551, Oklahoma City, OK 73152
OFFICE USE ONLY
Mail
Issuance
Front Desk
Reviewed by: ____________________
Copies Issued: ____________________________
Clerk: ______________________________
Date: ________ / _______ / ________
Date Completed: _______ / _______ / ________
Date: ______________________________
Fees Enclosed: $_________________
Issued by: ________________________________
Fees Paid: $ ________________________
Fees Due: $ _____________________
Other: ____________________________________
Fee Type:
Check
Cash
MO
ID Enclosed: _____________________
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