MINNESOTA BIRTH RECORD APPLICATION - CERTIFICATE OF BIRTH
This application must be signed in the presence of a notary public.
If boxes are incomplete the application may not be processed.
PART I: Name on Birth Record
FIRST NAME
MIDDLE NAME
LAST NAME
BIRTH MONTH
BIRTH DAY
BIRTH YEAR
SEX
CITY and COUNTY OF BIRTH
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: What is your relationship to the subject? (Please check only ONE.)
I am the subject.
I am the parent listed on the record.
I am the child of the subject.
I am the grandparent of the subject.
I am the spouse of subject.
I am the grandchild of the subject.
I am the party responsible for filing the birth record.
I am the legal custodian, guardian or conservator of the subject. (Must present certified copy of court order.)
I am a personal representative and the certified copy is required for the administration of the estate.
I have documentation that the record is necessary for the determination or protection of personal or property rights.
I represent an adoption agency and the record is needed to complete a confidential post-adoption search.
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.
I represent a local, state, or federal governmental agency and the vital record is necessary for the governmental agency to perform
its authorized duties.
I am a representative authorized by a person listed above. (Must enclose a notarized statement.)
PURPOSE FOR YOUR REQUEST:
PART III: Person applying:
APPLICANT'S FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF BIRTH
MAILING STREET ADDRESS ( If using a Post Office Box Number you must include a street address )
CITY
STATE
ZIP
DAYTIME PHONE NUMBER
E-MAIL ADDRESS
The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota Rules, part 4601.2600. 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 $3000 or both. (Minnesota Statutes section 144.227 and section 609.02, subdivision 3 and 4).
I certify that the information I provided on this application is accurate and complete to the best of my knowledge.
SIGNATURE:
DATE:
Please attach a copy of your valid Drivers license or State issued Identification card.
