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Michigan Birth Record - Application For Certified Copy - Michigan
| Michigan Birth Record - Application For Certified Copy Form. This is a Michigan form and can be used in General Statewide . |
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APPLICATION FOR A CERTIFIED COPY APPLICANT Applicant=s Name: MICHIGAN BIRTH RECORD Driver=s License or State Identification #: www.michigan.gov/mdch (PERSON REQUESTING RECORD) PLEASE PRINT CLEARLY AND LEGIBLY Address: City/State: Zip: Daytime Phone Required: ( ) Other Phone: ( ) To protect you from identity theft, we require PHOTO IDENTIFICATION to be presented along with this application. (See back for details) REQUESTED BIRTH RECORD INFORMATION If you cannot provide all of the following information, we may not be able to locate the record. NAME AT BIRTH STATE FILE NUMBER: __________________ (If Known) GENDER 9 Male 9 Female DATE OF BIRTH (mm/dd/yyyy) First Middle 9 Adoption 9 Legal Name Change Last IF THE PERSON ON RECORD IS ADOPTED OR HAS HAD A LEGAL NAME CHANGE (OTHER THAN MARRIAGE) PLEASE INDICATE THAT NAME HERE PLACE OF BIRTH: MOTHER=S NAME = BEFORE FIRST MARRIED: First Middle Last Hospital City FATHER=S = NAME: County First Middle Last First Middle Last Please provide any additional information that would help us locate the record, such as other names that the child or mother have used. PLEASE INDICATE PURPOSE FOR REQUESTING RECORD: Do you know if a birth record has ever been issued? 9 Yes 9 No ARE YOU ELIGIBLE TO REQUEST AND RECEIVE THIS BIRTH RECORD? PLEASE CHECK THE BOX THAT APPLIES TO YOU ELIGIBILITY: 9 9 9 9 9 Select the category that qualifies you to request and receive the requested Michigan birth record. 9 Heir of the deceased person named on birth record Provide information required below: Specify your relationship to decedent _____________________________ State where death occurred ____________________________________ Date of Death (Year) _________________ Decedent=s name at time of death _______________________________ Person named on record * Parent named on record * Birth record is at least 100 years old (no photo ID required) Court of competent jurisdiction (Court order required) Legal guardian of the person named on the record (Copy of court documented guardianship papers required) 9 Legal representative of the person named on the record (Official letter required; provide your state license number and name the person represented) * If the applicant=s name is different than the name as it appears on the requested birth record, provide information required below: Different due to marriage, indicate date of marriage: ____________________ and place of marriage (state): _______________________________ Or different for another reason, please explain: STATEMENT OF ENTITLEMENT: Misstating an identity or assuming the identity of another person is subject to criminal penalties, e.g., Michigan Compiled Laws 333.2894(b) and 333.2898 and federal laws relating to falsification in obtaining a birth record. By signing this application, I state that I am eligible to receive this birth record as indicated in the Eligibility Section of this application. K APPLICANT=S SIGNATURE: (Sign Here) _______________________________________________________________________________________ = MUST BE SIGNED, PHOTO IDENTIFICATION PROVIDED AND SEARCH FEE PAID IN ORDER TO PROCESS REQUEST BIRTH RECORD REQUEST FEES 3-Yr Search (Non-Refundable) One Certified Copy _________ Additional Certified Copies (Each) EXPEDITED A RUSH@ SERVICE @ (See back for details) (Additional) $ 26.00 $ 12.00 $ 10.00 $ SENIOR CITIZEN BIRTH RECORD REQUEST FEES AGE 65+ REQUESTING YOUR BIRTH RECORD Search (Non-Refundable) One Certified Copy $ _________ Additional Certified Copies (Each) $ EXPEDITED A RUSH@ SERVICE @ (See back for details) (Additional) $ 10.00 $ $ 12.00 $ $ 7.00 $ * Additional year search when exact date unknown. Each additional year $12.00. Specify which additional years to search: ____________________________ TOTAL ENCLOSED No. Yrs _______ $ 12.00 ea TOTAL ENCLOSED: $ $ $ DCH-0569-BX Rev 3/9/06 By Authority of MCL 333.2882(1)(a)(b) and MCL 333.2891(1-4)(8) American LegalNet, Inc. www.FormsWorkflow.com PAYMENT - NO ORDER WILL BE PROCESSED WITHOUT PROPER FEE SUBMITTED WITH A SIGNED APPLICATION AND PHOTO IDENTIFICATION SEARCH FEES ARE NON-REFUNDABLE: Fees are established by state statute. A search fee covers the cost of a basic 3-year search and includes either one certified copy of the record or an official statement that the record is not filed with the state. A basic search includes the files for the year specified as the birth year, as well as the year before and the year after. REFUNDABLE FEES: Payment for additional copies will be refunded if the search indicated that the record is not filed with the state. A refund check would be mailed to you by the Department of Treasury, usually within 3-4 weeks. * EXPEDITED (RUSH) SERVICE: Applies to standard three-year searches. Not available for extra year searches. APPLYING IN PERSON If you wish to apply in person to order a Michigan vital record, you may do so at the office located at 201 Townsend St, Capitol View rd Building, 3 Floor, Lansing MI 48913 (across from the State Capitol). Lobby hours are 8:00 am - 5:00 pm. Directions are available by logging onto our website at: www.michigan.gov/mdch or by calling 517-335-8666. A check or money order is preferred, and orders in our lobby must be placed by 3:00 pm in order to request same-day service. An additional fee of $10.00 is required for same-day service orders. Please allow a 2-3 hour waiting period for same-day service. PHOTO ID REQUIREMENTS FOR APPLYING IN PERSON OR BY MAIL FOR A MICHIGAN BIRTH RECORD * Please Send Photocopies - Not Original Documents * Under Michigan law, birth records are restricted documents, and a current valid, photo identification is required in order to establish eligibility to request and/or receive one (except for a birth record that is at least 100 years old). To protect you and the community from identity theft, we require a copy of the applicant=s photo identification to be presented along with the application. Individuals under the age of 15 are unable to request a copy of their own birth record. At least one of the following photo ID=s: = < Michigan driver=s license unexpired or expired for not more than one year < State of Michigan identification card unexpired or expired for not more than one year < Driver=s license or official identification card issued by another state in the U.S., jurisdiction or territory, unexpired, or expired for not more than one year. < Unexpired U.S. or foreign passport < U.S. military identification, military dependent identification or veteran
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