Form Hc1240 - Birth Certificate Application

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COUNTY OF HENNEPIN

DCN/Cert. # ________________

# of Copies: _____ Amount: $ _______

STATE OF MINNESOTA

ID Type

Initials & Emp #___________________

ID #

Issue Date: _______________________

BIRTH CERTIFICATE APPLICATION

NAME OF CHILD:

First

Middle

Last (name on birth record)

 Female

DATE OF

SEX OF

PLACE OF

 Male

BIRTH

MM/DD/YYYY

CHILD

BIRTH

City and County

PARENT’S NAME:

First

Middle

Maiden Name/Birth Name

PARENT’S NAME:

First

Middle

Maiden Name/ Birth Name

Make checks payable to: HENNEPIN COUNTY TREASURER:

Quantity and cost -

$26 first certified copy

$19 each additional copy of the same record issued at the same time as the first copy

$13 uncertified copy (applicant’s signature does NOT need to be notarized)

Please select only one:



I am the subject



I am the child of subject



I am the spouse of subject



I am the parent listed on the record



I am the grandparent of the subject



I am the grandchild of subject



I am the party responsible for filing the birth record.



I am the legal custodian, guardian or conservator of the subject. (must submit certified copy of court order showing relationship)

I am the health care agent of the subject (you must include the health care agent power of attorney)



I am a personal representative and the certified copy is required for the administration of the estate.

I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased.



I have documentation that the record is necessary for the determination or protection of personal or property rights. (you must

submit documentation showing this relationship)

I represent an adoption agency and the record is needed to complete a confidential post-adoption search. (you must submit a



copy of your employee ID)



I am an attorney and I have attached proof of my licensure.



I am presenting your office with a court order issued by a court of competent jurisdiction. (must be a CERTIFIED copy)





I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform its

authorized duties. (you must submit a copy of your employee ID)





I am a representative authorized by a person listed above. (must enclose a notarized statement from a person listed above.)

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 $3,000

or both. (MN Statutes section 144.227 and section 609.02, subdivision 3 and 4)

THE FOLLOWING INFORMATION IS ABOUT THE PERSON COMPLETING THIS APPLICATION

YOUR NAME:

DATE OF BIRTH:

MM/DD/YYYY

ADDRESS:

City

State

Zip

The information requested on this application is required by MN Statutes, Section 144.225, Subdivision 7 and MN Rules, Part 4601.2600. I certify that the information

provided on this application is accurate and complete to the best of my knowledge.

Reset Form

SIGNATURE:

DATE:

PHONE:

SUBMIT REQUESTS BY MAIL OR FAX TO:

Signature must be notarized (except for uncertified)

if applying by mail or fax

VITAL RECORDS

Hennepin County Government Center

Subscribed and sworn before me this ____day of_______, 20___

300 South 6th St, Suite A025