Michigan > Local County > Genesee
Application For Birth Record - Michigan
| Application For Birth Record Form. This is a Michigan form and can be used in Genesee Local County . |
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GENESEE COUNTY CLERK APPLICATION FOR BIRTH RECORD (Please Print) APPLICANT INFORMATION (Person Requesting Record) Applicant's Name: _____________________________________________________________________ Address: ____________________________________________________________________________ City/State/Zip: ________________________________________________________________________ Daytime phone number to contact you if there is a problem: ( APPLICANT'S SIGNATURE: ________________________________________________________ Must be Signed in Order to Process ELIGIBILITY - Are you eligible to request this birth record? Please check the box that applies to you: ELIGIBILITY: Michigan law limits who can receive a certified copy of a Michigan birth record. You must select which category qualifies you to receive the requested record. PERSON NAMED ON RECORD PARENT NAMED ON RECORD REQUESTED BIRTH INFORMATION Name at Birth: _______________________________________________________________________ First Middle Last Date of Birth: ___________________________ Month Day Year Place of Birth: ______________________________ City County ) ____________________________ Mother's Name: ______________________________________________________________________ First Middle Maiden Father's Name: ______________________________________________________________________ First Middle Last The fee is $10.00 for the first copy, and $5.00 for EACH ADDITIONAL COPY of the same record when ordered at the same time as the first copy. If the birth record is yours and you are 65 or older the fee is $2.00 for the first copy, and $1.00 for EACH ADDITIONAL COPY. Number of Copies Requested: ____________ Mail this application with a MONEY ORDER payable to: Genesee County Clerk Vital Records 900 S. Saginaw St. Flint, MI 48502 For additional information call (810) 257-3225 American LegalNet, Inc. www.USCourtForms.com
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