MINNESOTA CERTIFICATE OF BIRTH APPLICATION

The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
Make sure all boxes are complete or your application may be returned

PART I: Birth Record Information
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
PART IV: Requester
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
PART II: What is your relationship to the subject of the record (tangible interest)? You must check one.
  • I am the subject of the record
  • I am a parent listed on the recor
  • I am the child of the subject
  • I am the grandparent of the subject
  • I am the spouse of the subject
  • I am the grandchild of the subject
MINNESOTA CERTIFICATE OF BIRTH APPLICATION
Purpose for Your Request (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)

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
REQUESTER'S NAME

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).

MINNESOTA CERTIFICATE OF BIRTH APPLICATION
PART V: Fee and Payment Information
Item Number Fee per
Item
Total
One birth certificate 1 $26
Additional birth certificate(s) for the same person   $19 each  
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.
  $16  
Optional: Expedite
This is an additional fee that will place this request ahead of non-expedited requests.
  $20  
Total amount submitted or to be charged to credit card:
(This amount must be at least $26.)
 
  • Type of payment:
  • Credit Card
  • Money order
  • Check
If paying by credit card (MasterCard/VISA/Discover):
Name on card: Card number:
3 digit security code on back of card: Expiration date:
If paying by check or money order (make payable to Minnesota Department of Health):
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.


ABOUT TRUST ONLINE
U.S Birth Certificate . Com

ABOUT TRUST ONLINE
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 and fax both to us at 713-629-0396 or 713-785-1458. You will get an emailed sales receipt within 2 business days, your order will start processing immediately after you fax it to us, if there is a problem with your order we will call you. 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.
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: $49
Please charge me "total service fee $165" 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
Credit Card Number: Expires
Person's Name on Credit Card: CVC- Code ( Required)
Credit Card Billing Address:
CityState Zip
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


Ship Method: Express Courier           Date of Travel ( if applicable ):
Ship to Name:
Ship to Address:***( No P.O. Boxes )
CityState Zip
Daytime Telephone #  () -  - Extension:
Alternate Telephone #  () -  - Extension:
Email:
(REQUIRED)
Certificate Holders Signature:___________________________ Date
Credit Card Holder's 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,
the state of birth will charge your credit card seperately in some cases. 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. Our voice number is 888-629-2016.
All Sales Final

Once you fax your information to our office, if there is a problem we will call you.

** 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

Someone must be available to sign for the Federal Express. If no one is there, Fedex will leave a note on the door (with a tracking number) to let you know that they have tried to deliver your package. You will need to follow the instructions on the door tag to coordinate delivery of your package.

Please lighten and enlarge the copy of your drivers license before faxing. No scanned images please.

If you have ordered the passport package please read and follow the instructions on our passport section to be able to complete your passport application once your birth certificate arrives in your hands.

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.
Your privacy is important to us.Click here to read our privacy statement.
If you do not have access to a fax machine or would prefer to mail this order form to our office, please use the address below. If you mail this form and are paying with a money order please call our office so we can inform you of the total for your order.
Usbirthcertificate.com
Attn: Mail in Dept.
2600 South Gessner Rd. Ste 200
Houston, Texas 77063