Pennsylvania Department of Health - Division of Vital Records
Records available from 1906 to the present
By my signature below, I state
I am the person whom I represent myself to be herein, and I affirm the
information within this form is complete and accurate and made subject to the
penalties of 18 Pa.C.S. ¤4904 relating to unsworn falsification to authorities.
In addition, I acknowledge that misstating my identity or assuming the identity
of another person may subject me to misdemeanor or felony criminal penalties for
identity theft pursuant to 18 Pa.C.S. ¤4120 or other sections of the
Pennsylvania Crimes Code.
PRINT or TYPE your name &
credit card billing address (Certificate will only be mailed to your credit card billing address):
Name:
Address:
City:
State: Zip:
Daytime phone:
Relationship to person named on certificate:
Email Address:
Intended Use of Certified Copy:
Travel (Date Needed:)
Social Security / Benefits
School
Employment
Driver's License
Other (Reason:)
PHOTO ID REQUIRED: THE INDIVIDUAL REQUESTING THE RECORD MUST FAX A LEGIBLE COPY OF HIS OR HER GOVERNMENT ISSUED PHOTO ID ALONG WITH THIS COMPLETED APPLICATION. (Examples of acceptable ID: Valid state-issued driver's license or non-driver photo ID with requestor's current address, valid passport, etc.)
PRINT or TYPE below with regard to person named on requested
certificate: Number of copies:
Name at Birth:
Sex: Male Female
If name has changed since birth due to adoption, court order, or
any reason other than marriage, please list changed name here:
Date of Birth:
(Month/Day/Year)
Place of Birth:
(County and City/Boro/Township in Pennsylvania)
Age Now:
Full Maiden Name of Mother:
Full Name of Father:
In addition to the cost of $10.00** per certified copy, there is a $7.00 service fee to utilize a credit
card as method of payment. Complete this application and fax with legible
copy of ID
Select Courier: (Additional fee charged to credit card for express delivery)
First Class Mail
FedEx
UPS
Express Mail
Type of Credit Card:
Master Card
Discover
Visa American
Express
Cardholder's Name
Credit Card #
CVC*:
Expiration Date:
*Card Verification Code (CVC): Three-digit code is printed on the signature panel on the back of Visa and MasterCard debit/credit cards. Four-digit non-embossed code is located on the front of American Express cards.
** The $10.00 fee may
not be required for birth records of Armed Forces members and their
dependents. If selecting an express carrier, the $7.00 service fee will be
charged in addition to the express carrier charges. Please complete the
following information:
Armed Forces MemberÕs Name:
Service Number:
Relationship to Armed Forces Member:
Rank & Branch of Service:
U.S Birth Certificate . Com
What you will need to do is fill out the form below and hit the print button on your browser. Then make a copy of your driver’s license or your state issued identification card (if available) and fax both to us at 713-629-0396 or 713-785-1458. The box below that says V-Code means the last three numbers on the back of your Visa or Mastercard in the signature box. You will get an emailed sales receipt from us when your order has been processed by our office. Your birth certificate will be delivered by an overnight courier service, average delivery times are listed on the previous page. We cannot obtain birth certificates for Connecticut, Iowa, New Mexico or Hawaii. Requested through Google
PLEASE USE CAPITAL LETTERS ON THE FORM BELOW All Sales Final Fees: State Fee: $22.00-69.00 (Most are $35-$40) Plus Our Fee: $69.00 Please charge me "total service fee $185" for passport and birth certificate processing Emergency Birth Certificate Processing (additional fee $25.00)
Lifetime birth certificate & passport processing additional $99 (government/state fees excluded) Certified Birth Certificate Request
**Certificate will only be mailed to your credit card billing address **
Certificate Holders Name at Birth ( or adopted name):
(First)(Middle)(Last)
Fathers Name:
(First)(Middle)(Last)
Mother’s Full Maiden Name:
Maiden Last Name
(First) (Middle)(Last)
Certificate holders Birth Date State of Birth
County of Birth City of birth
Adopted or Legal Name Change excluding marriage
If adopted use adopted name and adopted parents names, Pre-adopted certificates are unavailable.
Hospital: Sex: Number of Copies
Person making this request
Date of Birth
Person making this request
Social Security #
Ship Method: Express CourierDate of Travel ( if applicable ):
Signature:___________________________________ Date
I authorize USBirthcertificate.Com to be my legal representative and to obtain my birth certificate for me.
USB.com will charge your credit card our fee upon receiving your request even if the information is incomplete.
USB.com will email a receipt confirming that we have received your request. Please contact us if the certificate
does not arrive by the stated process time. The lifetime birth certificate & passport processing service fee is
non refundable and can only be used for the person named on the birth certificate request. There are no refunds
of USBirthcertificate.com's services fees for any reason. By signing the form above you agree to these terms. All Sales Final
PLEASE FAX A COPY OF YOUR DRIVERS LICENSE IF AVAILABLE
(FOR MINORS PLEASE FAX A COPY OF THE PARENTS' LICENSE)
** State Fees may appear on your credit card asVCN NETWORK, or VCN then the state name or as Bureau of Vital Statistics
***You must list a physical street address (No APO's , FPO's or PO Boxes) where someone can sign for the certificate
Please lighten and enlarge the copy of your drivers license before faxing. No scanned images please. Please contact us if the certificate does not arrive by the stated process time. We can not process this request without a signature.
Please sign before faxing.
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