| CONSULAR VITAL RECORD SEARCH REQUEST FORM Important:This form must be signed in front of a notary |
| DATE:_________________PURPOSE OF REQUEST:_____________________________________ |
| NAME AT BIRTH:_________________________________________________________Sex__________________ |
| NAME AFTER ADOPTION (IF APPLICABLE)______________________________________________ |
| DATE OF BIRTH:____________________COUNTRY OF BIRTH:______________________________ |
| FATHER'S NAME:________________________________________________________________ |
| DATE & PLACE (STATE/COUNTRY) OF BIRTH:______________________________________________ |
| MOTHER'S FULL MAIDEN NAME:_______________________________________________________________________ |
| DATE & PLACE (STATE/COUNTRY) OF BIRTH:______________________________________________ |
| IF YOU POSSESS A REPORT OF BIRTH, 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 PASSPORT WAS NOT ISSUED TO THE SUBJECT):______________________________________ |
| CURRENT PASSPORT INFORMATION |
| NAME OF BEARER_________________________________________________________________________________ |
| Date of Issuance:_______________________________________PASSPORT NUMBER:____________________________ |
| SIGNATURE:_____________________________________________________________________________________ |
| (SUBJECT, PARENT, OR GUARDIAN) |
| SHIP TO 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 the change (i.e., foreign birth certificate, marriage certificate, court ordered adoption or name change, birth certificatesof adopting or legitimating parents, etc.). The original or replacement FS-240, 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 ONE REPLACEMENT ONLY)______________ ( NOTE: Request for an FS-240 MUST include the original FS-240 or a notarized affidavit attesting t0 its disposition.) |
| CERTIFICATION OF BIRTH (DS-1350) __________________(MULTIPLE COPIES AVAILABLE) For the following document $30.00 for first copy; $20.00 for each additional copy |
| CERTIFICATE OF ACKNOWLEDGMENT State of ____________________ ) County of ___________________) On ________________ before me, ________________________, notory public (here insert name and title of the officer), personally appeared______________________________________ (here insert name of signer above), who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of ________________that the foregoing paragraph is true and correct.--------------------------------------------------------------------------WITNESS my hand and official seal.---(SEAL) _____________________________________ Notary Signature |