CONSULAR VITAL RECORD SEARCH REQUEST FORM ( Must be Notarized )

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 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 certificates of 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 t 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