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