Form Dch-0855 - Application To Establish Delayed Registration Of Foreign Birth
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1
2APPLICATION TO
ESTABLISH DELAYED REGISTRATION OF FOREIGN BIRTH
PLEASE READ AND FOLLOW INSTRUCTIONS
MAIL APPLICATION AND PROPER FEE TO:
For additional information
Vital Records Changes
Vital Records Changes
P.O. Box 30721
(517) 335-8660 Mon-Fri 8:00 am – 5:00 pm ET
Lansing MI 48909
PARENT(S) INFORMATION
PLEASE PRINT CLEARLY AND LEGIBLY
Parent(s) names and complete mailing address are needed to mail the new record. Please provide a phone number to
contact you if there are questions regarding this request.
Name(s):
Mailing Address (Cannot send to General Delivery):
City/State/Zip:
Daytime phone to contact you:
Area Code & Number
-
-
INFORMATION REQUIRED TO PREPARE THE ADOPTIVE BIRTH RECORD
Child’s Name
First
Middle
Last
This Birth – Single, Twin, Triplet,
If Not Single – Born 1
st
nd
Gender
, 2
,
Date of Birth
Time of Birth
rd
etc. (Specify)
3
, etc. (Specify)
(Month, Day, Year)
Male
Female
Country of Birth
Mother’s Name (First, Middle, Last)
Mother’s State of Birth
Mother’s Date of Birth (Month, Day, Year)
(or Country, if not U.S.)
Mother’s Surname Before First Married
Mother’s Residence
Mother’s County of Residence
Mother’s State of Residence
Mother’s Social Security Number
Father’s Name (First, Middle, Last)
Father’s State of Birth
Father’s Date of Birth
(or Country, if not U.S.)
(Month, Day, Year)
Father’s Social Security Number
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