2. First Name
3. Middle Name
4. Last Name
   As it appears on birth record
6. Birth Date
   Birth Date
7. Sex

   1. Male
   2. Female
8. City and County of Birth
10. Mother's First Name
11. Middle Name
12. Maiden Name
14. Father's First Name
15. Middle Name
16. Last Name
18. Certification

    1. $26 Certified Record ($19 each additional copy of the same record)
    2. $13 Non-Certified Record ($6 each additional copy of the same record)
20. Tangible Intrest Required for a Certified Copy

    I am the:

    1. Subject
    2. Child of the subject
    3. Spouse of the subject
    4. Parent listed on the record
    5. Grandparent of the subject
    6. Grandchild of the subject
    7. Party responsible for filing the birth record (i.e. hospital, midwife, birth attendant)
    8. Legal custodian, guardian, or conservator of the subject (must submit certified court order showing this relationship)
    9. Personal representative and the certified copy is required for the administration of the estate (must submit documentation showing this relationship)
    10. Successor of the subject as defined by Minnesota Statutes, section 524.1-201, and the subject is deceased (must submit documentation showing this relationship)
    11. I have documentation that the record is necessary for the determination or protection of personal or property rights. (Must submit documentation showing this relationship)
    12. I represent an adoption agency and the record is needed to complete a confidential post-adoption search. (Must submit a copy of work identification)
    13. I represent a local, state, or federal government agency and it is necessary to secure a certified copy for authorized agency duties. (Must submit copy of work identification)
    14. I am an attorney and my proof of licensure is attached.
    15. I am presenting your office with a court order issued by a court of competent jurisdiction. (Must submit certified court document)
    16. I am a representative authorized by one of the above persons. (Must have a notarized statement in addition to the application)
22. Penalties
    Any person who willfully and knowingly makes false application for a birth certificate is guilty of a misdemeanor or gross misdemeanor (MN Statutes, section 144.227, subdivision 1).
26. The following information is about the person completing this application.
28. First Name
29. Middle Name
30. Last Name
32. Date of Birth
    Date of Birth
34. I certify that the information provided on this application is accurate and complete to the best of my knowledge.
36. Signature
37. Date
    Date
39. Address
41. City
42. State
43. Zip Code
45. Daytime Phone
49. Only requests for certified copies require notarization if applying by mail or fax.
51. Subscribed and sworn before me this date:
    Subscribed and sworn before me this date:
53. Notary Signature
54. My commission expires:
    My commission expires:
56. Seal
Leave This Blank:


57. Print Only

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