| 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 |