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The information requested on this application is required by Minnesota Statutes, section 144.225, subdivision 7 and Minnesota Rules, part 4601.2600. If you do not complete all fields, the application may be returned.
You must check one.
Application must be signed in front of a notary if applying by mail, fax, or email.
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
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 $3,000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
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