Application for a Birth Certificate


1 Y INTERNAL USE ONL Application for a H 105.102 18 / 6 REV 0 Initials: Initials: Date: Date: PO P M Delivery: Delivery: Birth Certificate BIRTH S R A Print or Type PART 1: APPLICANT naŵĞ͗ current legal DLJ (Middle) ffi (First) (Last) (Su x) Street: a Email ddress: City: c ode: Zip State: p hone: Daytime pplicants must be ϭΘ years of aŐe or : MY RELATIONSHIP TO PERSON NAMED ON BIRTH RECORD older or an emancipated minor to apply. Intended use of birth certificate: School icense Driver’s Travel/ p assport l Other: Employment /benefits Social S Dual citizenship ecurity ) . (Please specify other reason Please complete as much information as possible. PART 2: BIRTH CERTIFICATE BEING REQUESTED DATE OF BIRTH AGE NOW NAME AT BIRTH (Middle) (Suffix) (Last) (First) court order If name has changed , due to adoption or any reason other than marriage, please list since birth SEX that name here: Male Female (Firs t) (Middle) (Last) (Suffix) PLACE OF BIRTH TYPE OF BIRTH RECORD ity/ t (C ownship b orough/ ( Hospital name ) ) ) County ( PARENT/MOTHER'S NAME (First) first name (Last (Middle) prior to marriage) (Suffix) (Current last) PARENT/FATHER'S NAME (Suffix) (Current last) (First) (Middle) (Last marriage) first prior to name PART 3: ACCEPTABLE FORMS OF IDENTIFICATION 4 : FEE PART a legible photocopy of one of the following: I have included .00 $20 C : ertificate cost Make check or money order valid driver's license or other government-issued photo ID that A X Quantity : payable to "VITAL RECORDS." includes my mailing address. If applying by mail, the address on Total: listed above. my ID matches the mailing address Expired IDs cannot be accepted. — member of the U.S. armed forces Fee waiver Request The fee is waived if the applicant is requesting the certificate for self, Therefore, I I do not have a valid government-issued photo ID. spouse or a dependent child . have provided two current documents that verify my name and current address (such as a utility bill, pay stub, bank statement, I am or my current legal spouse (includes widow/widower if not car registration or lease/rental agreement). See remarried) is in active service or was honorably discharged from service. for further f Armed n ame: ember m orces information. Service n umber: APPLICANT PART 5 : SIGNATURE OF ervice: s ranch of b Rank and 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 HOW TO APPLY complete and accurate and made subject to the penalties of 18 at Order from P a. ’s only authorized online provider Pa.C.S.§4904 relating to unsworn falsification to authorities. In or by phone at 866-712-8238 (credit cards accepted). addition, I acknowledge that misstating my identity or assuming the Pennsylvania Vital Records branch office in Erie, Order in person at a identity of another person may subject me to misdemeanor or Delivery Harrisburg, New Castle, Philadelphia, Pittsburgh or Scranton. felony criminal penalties for identity theft pursuant to 18 five ranges from same day to days based on public office processing time. Pa.C.S.§4120 or other sections of the Pennsylvania Crimes Code. Send application, identification and payment to: Order by mail: Department of Health Records Division of Vital (Signature) (Date) PO Box 1528 Signature must agree with the name listed in Part 1 of this form. New Castle, PA 1610 3

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