Mdh Minnesota Certificate Of Birth Application (Page 3 of 3) in pdf

Mdh Minnesota Certificate Of Birth Application Page 3

MINNESOTA CERTIFICATE OF BIRTH

APPLICATION

This application must be signed in front of a notary public.

If boxes are left blank the application may be returned.

PART III: Fee and Payment Information

Total

Number

Item

Fee per

item

First birth certificate

$26

Additional certificate(s) for this birth record requested at this time

$19

Total:

PART IV: Requester and Notary Information

NAME (PLEASE PRINT)

DATE OF BIRTH

MAILING ADDRESS

CITY

STATE

ZIP

DAYTIME PHONE

EMAIL ADDRESS

I certify that the information provided on this application is accurate and complete to the best of my knowledge.

REQUESTER SIGNATURE

Please attach a copy of your valid driver’s license or state-issued ID.

NOTARY STAMP/SEAL

Sworn/affirmed to before me on ____ day of ___________, 20___

NOTARY PUBLIC SIGNATURE

MY COMMISSION EXPIRES

The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota

Rules, part 4601.2600.

PENALTIES: Any person who willfully and knowingly provides false information for a certified vital record may be sentenced

up to 1 year in jail or a fine of up to $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3

and 4).

If you have questions, please contact us at 218-732-3552.

B102 REV 05/2010

Mdh Minnesota Certificate Of Birth Application Page 3