Oklahoma Birth Certificate Request Form
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2OKLAHOMA BIRTH CERTIFICATE REQUEST FORM
STEP 1 - In order to accept this form, please read the following requirements:
•
This request must be completed in full (request will not be processed without the signature and photocopy of a legal photo I.D.
of the applicant, full fees, and established eligilbility of the applicant)
•
Enclose a copy of a current legal photo I.D. of the applicant (see back for a list of acceptable I.D.s)
•
If mailing, enclose all the appropriate fees and include a self-addressed stamped envelope (see back for mailing address)
Complete the fields below starting with the FULL NAME AT BIRTH: (If the birth name was legally changed, please see instructions on back)
First
Middle
Last
Male
Female
OKLAHOMA Birth City and/or County
Date of Birth (mm/dd/yy)
If child is less than age 2, List the name of Hospital or Midwife
Father’s First Name
Father’s Middle Name
Father’s Last Name
Mother’s First Name
Mother’s Middle Name
Mother’s Maiden Last Name (prior to first marriage)
This request is being made by:
(see eligibility instructions on back)
Subject of the record
Parent
Legal Guardian or Custodian
Authorized Agent, specify:
(
)
-
Your Name
Daytime Telephone Number
Current Mailing Address (Required)
APT#
City / State / Zip
No Email
E-mail Address
Purpose for which the birth
Drivers License
Social Security
Passport
School
State Assistance Pgm
Other:
certificate is needed:
STEP 2 - Complete the Order Information below:
QTY
PRICE SUB-TOTAL ITEM DESCIPTION
A NON-REFUNDABLE /
record search fee
$15
NON-TRANSFERABLE
Number of certified copies requested ($15 each and includes search fee)
of $15 includes the issuance of one
certified copy if the record is found;
$40
Delayed registration, amendment, paternity, adoption, or legitimation fee
additional copies are $15 each.
(includes one certified copy)
$35
If no record is found, the fee will not
Special Commemorative Heirloom Birth Certificate
be refunded. Should you receive a
request for more information, please
TOTAL AMOUNT ENCLOSED
respond promptly as all fees will
$ 0.00
DO NOT SEND CASH BY MAIL - Make checks payable to OSDH
expire one year after the date paid.
STEP 3 - Final Check & Sign
•
Check to see if you have filled out all of the information fields and you have followed all instructions in Step 1.
•
By signing below, you declare that all information provided on this request is true and correct:
Signature
Date Signed
OFFICE USE ONLY
Mail
Front desk
Reviewed By:
Date:
/
/
Clerk:
Date:
/
/
Fees Enclosed: $
Fees Due: $
Fees Paid: $
Check
Cash
MO
CC
ID Enclosed:
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