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MINNESOTA CERTIFICATE OF BIRTH APPLICATION
The information requested on this application is required by Minnesota Statutes, section 144.225, |
| First Name | Middle Name | Last Name |
| Date of Birth | Sex | City & County of Birth |
| Mother's First Name | Middle Name | Maiden Name |
| Father's First Name | Middle Name | Last Name |
| Name (please print) | Date of Birth | |
| MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O addresses) | ||
| City | State | Zip |
| Daytime Phone | Email Address | |
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I am the party responsible for filing the birth record
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I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a
court order showing this relationship)
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I am the health care agent of the subject (you must submit a health care agent power of attorney)
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I am a personal representative and the certified copy is required for the administration of the estate (you must submit
a sworn affidavit of the fact that the certified copy is required for administration of the estate)
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I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must
include a sworn affidavit of the fact that the certified copy is required for administration of the estate)
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MINNESOTA CERTIFICATE OF BIRTH APPLICATION |
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I have documentation that the record is necessary for the determination or protection of personal or property rights
(you must submit documentation showing this relationship)
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I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please
submit a copy of your employee ID)
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I am an attorney and I have attached proof of my licensure
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I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified
copy)
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I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to
perform its authorized duties (please submit a copy of your employee ID)
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I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a
person listed on the birth record)
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
| REQUESTER’S SIGNATURE | |||
| Signed or attested before me on: ___ day of _________________, 20__ | Notary Stamp/Seal | ||
| Notary Public Signature | |||
| My Commission Expires | |||
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).
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MINNESOTA CERTIFICATE OF BIRTH APPLICATION |
| Item | Number | Fee per Item |
Total |
| One birth certificate | 1 | $26 | |
| Additional birth certificate(s) for the same person | $19 each | ||
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Optional: Federal Express delivery This is an additional fee that applies only to the method of delivery.
Please check here if you want Federal Express to require a signature for
receipt. If you do not check this box, no signature will be required.
Federal Express will not deliver to P.O. boxes or A.P.O. addresses.
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$16 | ||
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Optional: Expedite This is an additional fee that will place this request ahead of non-expedited requests. |
$20 | ||
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Total amount submitted or to be charged to credit card: (This amount must be at least $26.) |
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| If paying by credit card (MasterCard/VISA/Discover): | |
| Name on card: | Card number: |
| 3 digit security code on back of card: | Expiration date: |
Check/money order number:
Due to high administrative costs, we are unable to issue refunds for overpayment.
Checks returned for non-payment will be charged a $30 fee according to Minnesota Statutes, section 604.113, subdivision 2
and civil penalties may be imposed.
If you submit this application to a local issuance office, Federal Express delivery and expedited service may not be an option. All payment types may not be accepted. Call the local issuance office before sending your application to confirm payment types and services available.