Minnesota Certificate of Birth Application

If you have questions, please contact us at [email protected]
B102 REV 09/2011
MINNESOTA CERTIFICATE OF BIRTH APPLICATION
The information requested on this application is required by Minnesota Statutes, section 144.225,
subdivision 7 and Minnesota Rules, part 4601.2600.
Make sure all boxes are complete or your application may be returned.
PART I: Birth Record Information
FIRST NAME
MIDDLE NAME
LAST NAME
DATE OF BIRTH
SEX
CITY & COUNTY OF BIRTH
MOTHER’S FIRST NAME
MIDDLE NAME
MAIDEN NAME
FATHER’S FIRST NAME
MIDDLE NAME
LAST NAME
PART II: Requester Information
NAME (PLEASE PRINT)
DATE OF BIRTH
MAILING ADDRESS (Federal Express will not deliver to P.O. boxes or A.P.O addresses)
CITY
STATE
ZIP
DAYTIME PHONE
PART III: What is your relationship to the subject of the record (tangible interest)? You must check one.
I am the subject of the record
I am the child of the subject
I am the spouse of the subject
I am a parent listed on the record
I am the grandparent of the
subject
I am the grandchild of the subject
I am the party responsible for filing the birth record
I am the legal custodian, guardian or conservator of the subject (you must submit a certified copy of a court order
showing this relationship)
I am the health care agent of the subject (you must submit a health care agent power of attorney)
I am a personal representative and the certified copy is required for the administration of the estate (you must submit
a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I am a successor of the subject as defined by MN statutes, section 524.1-201, and the subject is deceased (you must
include a sworn affidavit of the fact that the certified copy is required for administration of the estate)
I have documentation that the record is necessary for the determination or protection of personal or property rights
(you must submit documentation showing this relationship)
I represent an adoption agency and the record is needed to complete a confidential post-adoption search (please
submit a copy of your employee ID)
I am an attorney and I have attached proof of my licensure
I am presenting your office with a court order issued by a court of competent jurisdiction (this must be a certified
copy)
I represent a local, state or federal governmental agency and the record is necessary for the governmental agency to
perform its authorized duties (please submit a copy of your employee ID)
I am a representative authorized by a person listed on the birth record (you must submit a notarized statement from a
person listed on the birth record)
PURPOSE FOR YOUR REQUEST (optional)
PART IV: Notarized Signature (Requester must sign application in front of a notary if applying by mail or fax)
I certify that the information provided on this application is accurate and complete to the best of my knowledge.
REQUESTER’S SIGNATURE
Signed or attested before me on: _______ day of ____________________, 20_______
NOTARY STAMP/SEAL
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES:
PENALTIES: 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 $3000 or both (Minnesota Statutes, section 144.227 and section 609.02, subdivision 3 and 4).
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Minnesota Certificate of Birth Application PDF

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