Full Nam e AT BIRTH:
(IF THE BIRTH NAME WAS LEGALLY CHANGED, please see instruction on back) Male Female
____________________ ___________________________ ___________________________
First Middle Last
Date of Birth: _____ / ______ / _____ Place of Birth: _____________________ , OKLAHOMA
Month Da y Year City and/or County
Full Name of Father: _______ _____________ ___________ _____________ _______________________
First Middle Last
Full MAIDEN Name of Mother: __________ _______ ________________ ________________________________
First Middle Last Name prior to first marriage
This request is being made by:
(See elig ib ility instructions on the back o f this form)
Subject of the record Parent Legal Guardian or Custodian Authorized Agent, must specify: ______________ ____________________
Current Address (REQUIRED):
Name ___________________________________________________________ Daytime Telephone Number: (________) _______ - ________________
Mailing Address _______________________________________________Apt _______ City, State and Zip _____________________ _________
E-mail Address_______________________________________________________________ No email
Purpose for which the birth certificate is needed:
Passport School State Assistance Pgm Other, specify: _____________________ ___________________
By signing below, I declare that all information provided on this request is true and correc t.
Signature: ______________________________________ ____________________ Date Signed: _________________________________
(Request will not be pro cessed without the signature an d ID of the applicant, full fees, and established eligibility.)
If Child less than 2 yrs:
Name of Hospital or Mid wife
Division of Vital Records
Phone: 1000 NE 10
Street PO Box 53551 Walk-in Hours:
(405) 271-40 40 Oklahoma City, OK 73117 Oklahoma City, OK 73152 Mon-Fri 8:30-4:00
Birth Certificate Request
A fee is to be paid for a search of the files or records, even when no copy is available. Search fees are non-transferable and non-refundable.
_______ Number of certified copies requested ($15 each and includes search fee)
_______ Delayed registration, amendment, paternity, adoption, or legitimation fee ($40 - Includes one certified copy)
_______ Number of Heirloom certificates requested: ($35 each and includes one certified copy)
_______ Total Amount enclosed Make checks payable to OSDH. Do n ot send cash by mail.
OFFICE USE ONLY
Mail Front Desk
Reviewed by: ____________________ Date: ______ / _____ / ______ Clerk: ______________ Date: ________ / _______ / ________
Fees Enclosed: $_________________ Fees Due: $ _______________ Fees Paid: $ _______________
ID Enclosed: _____________________
1) This request must be completed in full.
2) Enclose a copy of a current legal photo ID (SEE BACK FOR LIST OF ACCEPTABLE IDS)
3) Enclose appropriate fees
4) Applicant must sign this form
5) If submitting by mail, enclose a self-addressed stamped env elope
NON-REFUNDABLE FEES: A record search is $15 and includes the issuance of one certified copy if the record is found; additional copies are $15 each.
If no record is found; the fee will not be refunded. The fee to amend a record is $40 ($25 processing fee + $15 for one certified copy). Should you receive a
request for more information, please respond promptly as all fees and files will expire one year after the date paid.