Form Vs-82b - Application For A Certified Copy Of A Birth Record Form
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Rhode Island Department of Health, Division of Vital Records, 3 Capitol Hill, Rm. 101, Providence, RI 02908-5097
Application for a Certified Copy of a Birth Record
Please complete ALL items 1-5 below:
1. Fill in the information below for the person whose birth record you are requesting:
Full name at birth _______________________________________________________ Age now_________________
New name if changed in court (excluding marriage)______________________________________________________
Date of birth
City/town of birth___________________ Hospital
Mother’s full maiden name_________________________________________________________________________
Father’s full name________________________________________________________________________________
2. I am applying for the birth record of (complete one of the following):
myself
my child
my mother/father
my grandchild (parent of mother)
my grandchild (parent of father)
my brother/sister
my client -- I’m a social worker. Name of my agency is_______________________________________
my client -- I’m an attorney representing:____________________________________________________
The name of the law firm is:
.
another person (specify your relationship):__________________________________________________
3. Why do you need this record? (We ask this question so that we can supply you with a certified copy that will be
suitable for your needs.)
school
license
vets benefits
social security
passport/travel
foreign govt
work
WIC
welfare
other use (specify)______________________
4. Copies cost $20.00. Any additional copies of this record purchased this same day cost $15.00 each.
How many copies do you want? _______________________(Payable to: Town of Foster)
5. I hereby state that the information supplied in item #2 above is true and that I am not in violation of Section
23-3-28 of the General Laws of RI (printed on the reverse side of this form).
Please sign_____________________________________________________________ ______________________
Signature of person completing this form
date signed
Print your name_______________________________________________
(
)___________________________
phone #
Print your address_______________________________________________________________________________
street or mailing address
city/town
state
zip code
ATTACH VALID GOVERNMENT ISSUED PICTURE ID
VS-82B (Rev. 08/01/07)
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