Michigan > Local County > Oakland > Family Division
Application To Establish Delayed Registration Of Foreign Birth DCH-0855 - Michigan
| Application To Establish Delayed Registration Of Foreign Birth Form. This is a Michigan form and can be used in Family Division Oakland Local County . |
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APPLICATION TO ESTABLISH DELAYED REGISTRATION OF FOREIGN BIRTH PLEASE READ AND FOLLOW INSTRUCTIONS For additional information: Vital Records Changes (517) 335-8660 Mon - Fri 8:00 am to 5:00 pm ET MAIL APPLICATION AND PROPER FEE TO: Vital Records Changes P.O. Box 30721 Lansing, MI 48909 PARENT(S) INFORMATION PLEASE PRINT CLEARLY AND LEGIBLY Parents(s) name and complete mailing address are needed to mail the new record. Please provide a phone number to contact you if there are questions regarding this request. Name(s): Mailing Address: City / State / Zip: Daytime Phone to Contact You: Area Code & Number - INFORMATION REQUIRED TO PREPARE THE ADOPTIVE BIRTH RECORD Child's Name First Middle If Not Single - Born 1st, 2nd, 3rd, etc. (Specify) Last Gender Male Female This Birth - Single, Twin, Triplet, etc. (Specify) Date of Birth (Month, Day, Year) Time of Birth Country of Birth Mother's Name (First, Middle, Last) Mother's State of Birth (or Country, if not U.S.) Mother's Date of Birth (Month, Day, Year) Mother's Surname Before First Marriage Mother's Residence Mother's County of Residence Mother's State of Residence Mother's Social Security Number Father's Name (First, Middle, Last) Father's State of Birth (or Country, if not U.S.) Father's Date of Birth (Month, Day, Year) Father's Social Security Number American LegalNet, Inc. www.FormsWorkflow.com SIGNATURE(S) This form should be signed by the adoptive parents with their current names. The adoptive parents should verify information listed for the adoptive birth record. Signature of Person Adopting Signature of Husband or Wife (if married) COURT CERTIFICATION The Probate Court of County, Michigan I hereby certify that this Court has acknowledged the birth facts of the foreign born child, and the identified information about the adoptive parents dated Month Day Year . CASE NO. Judge By Probate Register SEAL OFFICE USE ONLY - DO NOT WRITE IN THIS AREA PAYMENT - The fee for establishing a delayed registration of foreign birth is $40.00 and includes one copy of the new record. Additional copies of the new record are available for $5.00 each when ordered at the same time. Payment must be made by check or money order and made payable to the "State of Michigan." The new birth record will not be created until the recording fee has been paid. Establish Delayed Registration of Foreign Birth (Non-Refundable) Fee includes one (1) certified copy of the record PENALTIES: Any person who willfully and knowingly makes false application to change a Michigan birth record may be fined not more that $1,000 and/or imprisoned not more than one (1) year. MCL 333.2894(1)(b) and (c). $40.00 $40.00 Additional Certified Copies $ 12.00 Each Total Enclosed $ $ American LegalNet, Inc. www.FormsWorkflow.com DCH-0855 Rev 01/2005 MCL 333.2830(1) and 333.2891(5)(b).
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