Consular Vital Record Search Request Form - District Of Columbia Department Of State Page 2
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1
2MAIL THIS FORM TO:
TH
PASSPORT CORRESPONDENCE BRANCH,1111 19
ST NW,SUITE 510,WASHINGTON DC 20524.
CONSULAR VITAL RECORD SEARCH REQUEST FORM
DATE: _________________ PURPOSE OF REQUEST: ____________________________________
NAME AT (CIRCLE ONE)
BIRTH/DEATH/MARRIAGE: __________________________________________________________
NAME AFTER ADOPTION (IF APPLICABLE): ___________________________________________
DATE OF (CIRCLE ONE)
COUNTRY OF (CIRCLE ONE)
BIRTH/DEATH/MARRIAGE: ____________
BIRTH/DEATH/MARRIAGE: ______________________
FATHER’S NAME:__________________________________________________________________
DATE & PLACE (STATE COUNTRY) OF BIRTH:__________________________________________
MOTHER’S NAME: _________________________________________________________________
DATE & PLACE (STATE COUNTRY) OF BIRTH: _________________________________________
IF YOU POSSESS A REPORT OF BIRTH/DEATH OR CERTIFICATE OF WITNESS TO MARRIAGE,
PLEASE ENCLOSE A COPY TO AID IN OUR FILE SEARCH.
PASSPORT – FIRST ENTRY INTO THE UNITED STATES
NAME OF BEARER:_________________________________________________________________
DATE OF ISSUANCE: ___________________ PASSPORT NUMBER: _________________________
DATE OF INCLUSION (IF PASSPOR
T WAS NOT ISSUED TO THE SUBJECT): _________________
CURRENT PASSPORT INFORMATION
NAME OF BEARER: ________________________________________________________________
DATE OF ISSUANCE: __________________ PASSPORT NUMBER: __________________________
SIGNATURE: _____________________________________________________________________
(SUBJECT, PARENT OR GUARDIAN)
ADDRESS: ____________________________________ TELEPHONE (DAYTIME):______________
_____
__
_________________
NOTICE: If you are requesting an amendment or correction to a Consular Report of
Birth Abroad, please include certified copies of all documents appropriate for
effecting change (i.e. foreign birth certificate, marriage certificate, court
ordered adoption, birth certificates of adopting or legitimating parents, etc.)
The original replacement FS240, or a notarized affidavit concerning its
whereabouts also must be included.
PLEASE INDICATE THE NUMBER OF DOCUMENTS DESIRED
REPORT OF BIRTH (FS-240) ($30.00 ONLY ONE COPY AVAILABLE)
(Note: Request for an FS240 must include the original FS240 or a notarized
affidavit attesting to its disposition.)
For the following documents $30.00 for first copy; $20.00 for each additional
copy:
CERTIFICATION OF BIRTH (DS-1350)
_______ (MULTIPLE COPIES AVAILABLE)
REPORT OF DEATH
_______ (MULTIPLE COPIES AVAILABLE)
CERTIFICATE OF WITNESS TO MARRIAGE
_______ (MULTIPLE COPIES AVAILABLE)
CERTIFICATE OF NO RECORD
_______ (MULTIPLE COPIES AVAILABLE)
Check or Money Order must be signed, dated, and made payable to Department of State.
Remittance must be payable in U.S. dollars through a U.S. bank.
PLEASE DO NOT SEND CASH
UK/560
04/05
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