MINNESOTA BIRTH RECORD APPLICATION - CERTIFIED BIRTH CERTIFICATE
This application must be notarized or signed in the presence of a registrar.
SUBJECT'S FIRST NAME
MIDDLE NAME
LAST NAME ON BIRTH RECORD
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
$16.00 First certified record
$ 9.00 Each additional copy of the same record issued at the same time
1.
I am the:
subject
child of the subject
spouse of subject
parent of subject
grandparent of the subject
grandchild of the subject
2.
I am the party responsible for filing the birth record.
3.
I am the legal custodian, guardian or conservator of the subject. (Must present legal documentation)
4.
I am a personal representative and the certified copy is required for the administration of the estate.
5.
I am a successor of the subject, as defined in MN Statutes section 524.1-201, if the subject is
deceased and the certifiedcopy is required for the administration of the estate.
6.
I can demonstrate that the information from the record is necessary for the determination
or protection ofpersonal or property rights pursuant to rules adopted by the commissioner
of health. (Requests must be approved by the State Registrar)
7.
I represent an adoption agency and the record is needed to complete a confidential
post-adoption search.
8.
I represent a local, state or federal governmental agency and it is necessary to secure a
certified copy for authorizedagency duties.
9.
I am an attorney and my attorney license number is .
10.
I am presenting your office with a court order issued by a court of competent jurisdiction.
11.
I am a representative authorized by a person under items #1-10. (Must have a notarized statement in addition to the application)
APPLICANT'S FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF BIRTH
STREET ADDRESS (No Post Office Box Numbers Without a Street Address Please)
CITY
STATE
ZIP
PHONE NUMBER
PENALTIES: Any person who willfully and knowingly makes false application for a certified vital record is guilty of a misdemeanor or gross misdemeanor (Minnesota Statutes section 144.227).
INFORMATION REQUIRED: The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota Rules, part 4601.2600. I certify that the information I provided on this application is accurate and complete to the best of my knowledge.
Applicant's Signature: Today's Date:
Signature must be notarized if applying by mail or fax.
