Application for a Copy of a North Carolina Birth Certificate


1 North Carolina Department of Health and Human Services Division of Public Health N.C. Vital Records • Telephone: 919-733-3000 Mail: 1903 Mail Service Center Location: 225 North McDowell St. Raleigh, NC 27603-1382 Raleigh, NC 27699-1900 PLEASE PRINT Application for a Copy of a North Carolina Birth Certificate _________________________________________________________________ Full Name on Certificate First Name Last Name Middle Name (If adopted, provide new information)  Sex  Male Female ____ | ____ | ________ Date of Birth Year Month Day Were parents married at time of birth? No Yes   _________________________________________ Place of Birth County City  Yes Is this person deceased?  No Full Name of Mother/Parent ___________________________________________________________________ Middle Name Last Name prior to first marriage, if applies Last Name First Name (Adoptive parent, if applies) Full Name of Father/Parent ___________________________________________________________________ Last Name prior to first marriage, if applies Last Name (Adoptive parent, if applies) Middle Name First Name Check all boxes that apply; add the fees in 1–3 Your Relationship to the Person Whose Certificate is Requested: and place the total amount in #4. See further instructions on Page 2. ( Check One) — Authorized agent, attorney or legal representative of   Self Order 1. Certificate — the person listed (Proof REQUIRED ) Processing times vary. Spouse (Current)  Check website for current information. — Other (may not be entitled to a certified copy)   Brother/Sister (Non-refundable fee) Specify:  Child/Stepchild —  ______ $ Certificate Search and First Copy ($24) Parent/Stepparent  — ______  #____ additional copies x $15 $  Grandparent  Certified —  Grandchild (Suitable for legal purposes) How do you plan to use this record?  Uncertified (Not suitable for legal purposes) Record Changes (Only if applies) 2. Appointment required for in-person services. (Please Print) ($15 non-refundable processing fee) Requestor ______________________________________________________________ : Print Name of Person Requesting the Certificate  Adoption $ ______ ______________________________________________________________ Address : ______  $ Amendment Street Address (P.O. Box cannot be used for expedited shipping) ______ Name Change $  _________________________________________________________________________ $ ______  Legitimation Court Order P.O. Box (If mailing to a P.O. Box, street address must also be listed above) Legitimation (mother married father  after child’ ______ $ s birth) _________________________________________________________________________ OMER MUST COMPLETE City, State and Zip Code 0.00  Paternity (no fee) $ Other _____________________ $ ______  _________________________________________________________________________ (Area Code) Telephone Number (During business hours) CUST Faster Service (Choose only one) 3. Optional for mail-in requests- write “Expedite” Must Email Address ___________________________________________________________ : — on the outside of the envelope. ($15 non-refundable expedite fee) P Please pay with a cashier’s check or money order made payable to N.C. Vital ayment: — Records. Personal checks are not accepted. Requests that are submitted with no payment  ______ $ alk-in Service ($15) W — or incomplete payment or incomplete information will be returned. Credit card payment is  Expedited Processing ($15) $ ______ (Shipped by regular mail) available for walk-in customers. — Expedited Processing and  — IDENTIFICATION OF THE PERSON REQUESTING A CERTIFICATE Expedited Shipping ($35) $ ______ (Call for expedited shipping fees outside the continental United States) IS REQUIRED. — See Page 2 for a list of acceptable IDs. 4. Total Fees ______ (Add 1+2+3 above for total) $ I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of North Carolina Law (G.S. 130A-26A) to make a false statement on this application or to unlawfully obtain a copy or a certified copy of a birth certificate. ___________________________________________________________ ______________________________________________ Signature of Person Requesting the Certificate Date Signed Office Use Only: SFN _______________________________ DCN _____________________________ Cartridge/Frame _______________________________________ Amount received: $_______________________ Identification presented_______________________________________________________________________________ Request number ___________________________________________ Request date _____________________________________________________________________ (Revised 12/2018) DHHS-VR-B N.C. Vital Records

2 Order Certificate A certificate search costs $24 and includes one copy if the certificate is located. The search covers a three year period. Requests are processed in the order received and can take up to five weeks plus the mail delivery time. The search fee is required to process a request and is non-refundable even if a record cannot be located. Record Changes The $15 Complete this section only if you are making a request to change information on the birth certificate. processing fee to review your request is non-refundable. In-person assistance for this service is by appointment only. Please call (919) 792-5986 to schedule an appointment. If your request involves more than one birth record, the $15 processing fee applies to each individual’s birth record that requires change(s). Faster Service To receive expedited service you MUST write “Expedite” on the outside of the envelope. This is a non- refundable fee. For current processing times for expedited requests, see our website at https://vitalrecords. Identification Requirement Due to identity theft and other fraudulent use of vital records, ID of the person requesting a certificate is REQUIRED. Requests that do not include ID will be returned . You MUST include a legible photocopy of one of the photo IDs listed below with your request: • Current state-issued driver’s license (address must match requestor’s address on application) ’ s address on application) • Current state-issued non-driver photo ID card (address must match requestor • Current Passport or Visa (must include photo) • Current U.S. military ID • Current Department of Corrections photo ID card dated within the last year • Current state or U.S. government agency photo ID card (for persons requesting certificates as part of that agency’s business) • Current student ID card with copy of transcript If you do not have one of the IDs listed above, you must provide legible photocopies of TWO of the following (must be two DIFFERENT forms of ID): • Temporary driver’s license • Current utility bill with current address • Car registration or title with current address • Bank statement with current address • Pay stub with current address • Income tax return/W-2 form showing current address • Letter from government agency dated within the last six months and showing current address • State-issued concealed weapon permit showing current address If you are unable to meet our ID requirements, a family member or other person equir ements, may request it. who is entitled to obtain the certificate, and who can meet the ID r A list of persons entitled to obtain certificates is located on our website at (Revised 12/2018) DHHS-VR-B N.C. Vital Records

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