Request For A Certified Copy Of A Birth Record From The State - State Of Connecticut Department Of Public Health
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1STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH
VITAL RECORDS SECTION, CUSTOMER SERVICES
410 CAPITOL AVENUE, MS #11VRS
P.O. BOX 340308
HARTFORD, CT 06134-0308
REQUEST FOR A CERTIFIED COPY OF A BIRTH RECORD FROM THE STATE
FEE: $30.00 PER COPY. REMIT MONEY ORDER MADE PAYABLE TO: ‘TREASURER, STATE OF CT’
PLEASE PRINT
FULL NAME ON CERTIFICATE*:________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
DATE OF BIRTH: ________/________/________
PLACE OF BIRTH: _____________________________________________
MONTH
DAY
YEAR
TOWN/CITY
FATHER’S FULL NAME: ________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
MOTHER’S MAIDEN NAME: ____________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
PERSON MAKING THIS REQUEST:
NAME: ________________________________________________________________________________________________________
FIRST
MIDDLE
LAST NAME
ADDRESS: _____________________________________________________________________________________________________
NUMBER/STREET/UNIT #
TOWN/CITY: __________________________________________________ STATE: _____________ ZIP CODE: _____________
TELEPHONE NO: ____________________________________ E-MAIL ADDRESS: ______________________________________
SIGNATURE: X_________________________________________________________________________________________________
RELATION TO PERSON NAMED ON CERTIFICATE: ______________________________________________________________
REASON FOR MAKING REQUEST: ______________________________________________________________________________
CERTIFICATE SIZE:
TOTAL NUMBER OF COPIES:
FULL SIZE
WALLET SIZE
The wallet size birth certificate contains less
_______ X $30.00 = $ _______
information than the full size certificate. It
does not satisfy the proof of identification
SEND POSTAL MONEY ORDER ONLY
requirements needed for a passport or driver’s
license.
DO NOT MAIL CASH OR PERSONAL
NUMBER OF COPIES: __________
CHECKS - THEY WILL NOT BE
NUMBER OF COPIES: __________
ACCEPTED.
Attach a copy of the requester’s valid government issued
Please mail the completed request with the following
photo ID or passport below:
requirements:
Or two (2) forms of the following:
Money order made payable to ‘Treasurer, State of CT’
Current government issued photo ID
-
Social security (SS) card
(If applicable) verification of relationship to the
-
Paycheck Stub or a W-2 form showing SS #
registrant (for example, an individual requesting
-
Current school or college photo ID
his/her parent’s birth certificate must provide a
-
Automobile registration
certified copy of his/her own birth certificate).
-
Copy of utility bill or bank statement showing name and
address
-
See our website ct.gov\dph for other forms of ID accepted
*If adopted, please provide your adoptive name and adoptive parents’ information
.
Birth Request REV 5-12
*If the requester had a legal name change, please provide a copy of the court documents authorizing the name
change.
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